A.C.T.S. YOUTH MINISTRY OURLADY OF GUADALUPE VOLUNTEER PERMISSION SLIP

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OUR LADY OF GUADALUPE CELEBRATION PERMISSION SLIP

Email *

CHILD'S LAST NAME / APELLIDO DE SU HIJO/A *

CHILD'S FIRST NAME / PRIMER NOMBRE DE SU HIJO/A *

HOME PHONE / TELE DE CASA

CHILD'S CELL PHONE / CELL DE NIÑO/A

CHILD'S EMAIL/ CORREO ELETRONICO DE NIÑO/A

CHILD'S SCHOOL / ESCUELA DE NIÑO/A *

CHILD'S CURRENT GRADE /GRADO DE NIÑO/A *

DATE OF BIRTH / FECHA DE NACIMIENTO *

YYYY

ADDRESS / DOMICILIO *

FATHER'S LAST NAME / APELLIDO DE PAPA

FATHER'S FIRST NAME / PRIMER NOMBRE DE PAPA *

FATHER'S CELL PHONE/ NUMERO CEL DE PAPA

MOTHER'S LAST NAME / APELLIDO DE MAMA

MOTHER'S FIRST NAME/ PRIMER NOMBRE DE MAMA

MOTHER'S CELL PHONE/ NUMERO CEL DE MAMA

DESIGNATED ACTIVITY

OUR LADY OF GUADALUPE CELEBRATION, STUDENTS WILL BE HELPING TO SERVE FOOD AT THE SCOIAL.

EVENT LOCATION: ST. PATRICK'S CRISTO REY HALL, 1111 Douglas Avenue 53402

DATES OF ACTIVITY

THURSDAY DECEMBER 12, PLEASE ARRIVE BY 5PM

MODE OF TRANSPORTATION

YOUR OWN

DEPARTURE TIME

5PM

RETURN TIME

9PM

DESIGNATED SUPERVISOR

ELOY CONTRERAS 262-664-3111

STUDENT COST (IF APPLICABLE )

NONE- COUNTS AS COMMUNITY SERVICE

RELEASE AND WAIVER

MEDICAL INFORMATION *

In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.

Required

MEDICAL INFORMATION AND RELEASE *

On field trips that occur during the length of the school day, any prescription medication already provided to the school will be carried and administered by staff.

Required

IN CASE OF AN EMERGENCY

If are are unable to reach a parent/guardian at the above number, please contact:

EMERGENCY CONTACT / CONTACTO DE EMERGENCIA *

EMERGENCY CONTACT PHONE / TELEFONO *

AGREEMENT *

By Checking this box I am certifying that I am 18 YEARS of age or older and are the Parent / Guardian of the above referenced child.

Required

PERMISSION *

I consent to the participation of my CHILD/WARD in ACTS RACINE YOUTH MINISTRY ACTIVITIES. In consideration for my CHILD/WARD's participation, I agree to reimburse and indemnify the ACTS (understood to include The Archdiocese of Milwaukee) for all reasonable legal and court fees incurred by ACTS YOUTH MINISTRY in defending a lawsuit that I or my CHILD/WARD may bring against the PARISH/SCHOOL which relates ANY ACTS Youth Minstry Activitty is found not legally liable by the courts and prevails in the lawsuit. If the PARISH/SCHOOL is found legally liable for injuries sustained by CHILD/WARD, this paragraph will not apply. I certify that I have an understanding of this agreement and any risks and hazards associated with the ACTIVITY described above that my CHILD/WARD will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the PARISH/SCHOOL to clarify any concerns or questions about the ACTIVITIES or this agreement that I may have had.

Required

PHOTO RELEASE *

I hereby consent that any still or electronic image and/or audio recording, in which I or my child may appear, may be used by ACTS Youth Ministry, and/or by the Archdiocese of Milwaukee. I understand that these materials are being used for promotion of ACTS Youth Ministry. and/or the Archdiocese of Milwaukee. The images and/or recordings may be used to support recruitment, fundraising, evangelization and other communication efforts. I release the staff and volunteers and I understand and agree that the use of my picture is not an invasion of privacy. Neither I, nor anyone claiming to be speaking on my behalf, will later object to the Archdiocese’s use of this/these photographs. I give permission to have my/my child(ren)(s) address and phone number published in the school directory.

Required

WHAT PARISH IS YOUR FAMILY REGISTERED TO? *

ST. PATRICK

ST. RICHARD

ST. EDWARD

Other:

A copy of your responses will be emailed to the address you provided.

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