Diocese of Palm Beach Activity Release Form

Participant Information

Name:______________________________________________ Phone:____________________

Street: ______________________________________________________________________

City: __________________________State: ____ Zip: _______ E-mail: _____________

Mother's Name: _________________________ Father's Name: ______________________

Parent's address (if different from your own)

Street: ______________________________________________________________________

City: ____________________________________________ State: ____ Zip: __________

Insurance Company: ________________________________ Policy No.: ______________

Activity Information

Parish: ______St. Sebastian________________________________________________________________

Activity:

Rock the Universe

Place: Orlando, FL

Date of Activity: Sept 6th

and 7th, 2008

Adult Chaperone: __Bud Zielinski________________________________ Phone: ___Cell 321-427-6789________________

Permission and Medical Treatment Waiver

I, ___________________________, the parent/guardian of _______________________

do hereby give my permission for him/her to attend the above activity and to be treated for a medical emergency in my absence

while participating in the Youth Ministry program.  The Youth Minister or Adult supervisor may act as an agent

in my absence.  In case of accident, I do not hold the Diocese of Palm Beach, the parish, its staff, or the adult chaperones

responsible.

In case of emergency, if I am not available at the above address and phone, please contact:

Name: ____________________________________________ Phone: _____________________

Parent/Guardian Signature: __________________________________ Date: ___________

Special Dietary Needs: ________________________________________________________

Parent's Authorization for Travel

I hereby give my consent for my daughter/son:_________________________________

to participate in ____Rock the Universe

including traveling from: _______Sebastian, FL to Orlando FL____________________________________________

The group will be traveling by ___Private

Vehicle

I understand that although the diocese/parish is sending a representative with the youth, it would be impossible for the

representative to supervise every individual activity and action of the youth.

I understand that neither the Diocese of Palm Beach, the parish, the parish youth minister, the parish chaperone nor the staff is

liable in the event of an accident or injury to my child.  I also assume full responsibility for the

consequences of my child's actions during these activities.

__________________________________

_____________________________________

Signature of Parent or Legal Guardian

Date

Diocese of Palm Beach

Hold Harmless Agreement

I,___________________________________________ hereby agree to assume full

responsibility for the payment of all debts incurred by my child

_____________________________________during his/her visit to NCYC and to reimburse the Diocese

of Palm Beach (and any other participating organizations) for any damages suffered by it due to

my child's acts during the trip.

I further agree to release and hold the Diocese of Palm Beach (and any other participating

organizations) harmless for and against all claims, judgments, costs or other expenses arising

out of bodily injuries, property damage, or other loss suffered by my child during the trip.

I authorize the Diocese of Palm Beach (and any other participating organization) to procure, at

my expense, any medical care reasonably required for my child during the trip.

In the event of an emergency, please notify:

Name:__________________________________________________

Address:_______________________________________________

City, St., Zip:________________________________________

Phone:(_____)__________________________________________

Signature:_____________________________________________

Date:____________________________