Escape Breakout Room June 2nd! ONLY Cost is dinner

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I request that my child(ren) be allowed to participate in the Escape Room on June 2, 2019 from 3:00 pm - 6:00 pm. I understand the purpose of this event is Community Building. I further give permission for my child(ren) to ride in any vehicle designated by the adult in whose care my child(ren) has been entrusted while participating in said activities.

In consideration of permitting my child to attend and/or participate, I do hereby, for myself and my child(ren) waive and release any and all claims that I might have against Fr. Dave Harris, Pastor, or any employee of St. Albert the Great, the institution of St. Albert the Great, the Archdiocese of Louisville and any designated driver of a van, bus, car or other vehicle, for any and all injuries or losses suffered by said child(ren) while engaged in the above activities.

In case of any medical emergency, In understand that every effort will be made to contact the parents or guardians of the child participating in the Youth Ministry Programming of the parish. In the event that I cannot be reached, I hereby give permission to the physician selected by the Youth Ministry Coordinator, or adult in charge, to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named herein.

I also give permission for the use of photographs/video, which may include my child(ren) to be used by St. Albert the Great youth ministry and/or the Archdiocese of Louisville for promotional purposes. This includes but is not limited to bulletin boards, newsletters, St. Albert the Great Website and/or St. Albert YouthMinistry Facebook.

Name of parent (guardian) *

Name of Child *

Parent Phone to contact: *

Youth Phone to contact:

Parent Email: *

Youth Email:

Adult Chaperones/Drivers are needed! I am willing to chaperone this event: *

Yes

I will provide a current Annual Youth Ministry Permission/Medical Release Form *

Yes

AGREEMENT: By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. PARENT/GUARDIAN PRINT FIRST AND LAST NAME AND DATE: *

I Understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document. *

My "signature"

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