2019 Holy Fire Permission Form
Contact:
James Holzhauer-Chuckas, ObSB
Regional Director, United Catholic Youth Ministries
847-864-1185 x26 | JAMESHC@ucym.org

Day 1: Friday, October 18
Day 2: Saturday, October 19
9 am to 3 pm at Credit Union 1 Arena (formerly UIC Pavilion)

COST: $20 per student
-Cash can be dropped off to your parish or the day of
-Online (please put "Holy Fire" in the notes): https://membership.faithdirect.net/givenow/IL909/30112
-Check (payable to "Your Parish" with "Holy Fire" in the memo line)
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First & Last Name of Teen Participant *
Grade of Participant *
Home Parish *
Parent/Guardian First & Last Name *
Parent/Guardian Cell Phone # *
PERMISSION FORM
An adult over the age of 18 and is a responsible party of the teen participant must sign. Please read carefully!
EMERGENCY CONTACT (please write FIRST & LAST NAME of person, phone #, RELATION TO PARTICIPANT *
MEDICAL AUTHORIZATIONS: In the event that the undersigned cannot be reached, and in the judgment of the responsible adults or other appropriate staff members accompanying the group, if there is a necessity for immediate examination and/or treatment of my child I hereby authorize any of the aforesaid personnel to obtain for my child such medical services as are deemed necessary. I GRANT PERMISSION for the Youth Council personnel to administer non-prescription drugs as advised by the Youth Director as needed for my teen (aspirin, ibuprofen, etc.) *
PHOTO RELEASE: I AUTHORIZE the Parishes of the Evanston & Skokie Archdiocesan Grouping to use photographs/videos of my child strictly for church-related productions, publications, etc. *
LIABILITY WAIVER: I hereby give permission for my teen to participate in Holy Fire 2019 on behalf of United Catholic Youth Ministries of Evanston & Skokie. I hereby release and indemnify the Archdiocese of Chicago, the catholic parishes of the Evanston & Skokie Grouping of the Archdiocese of Chicago, its staff and volunteers, and the Catholic Bishop of Chicago, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in the program. I understand that if my child violates any laws regarding possession of alcohol or drugs, or rules governing the program, I will be called and notified about the situation and/or arrangements made to send my child home at my expense during any event. Please write FULL NAME AND RELATION TO TEEN of adult signing for teen participant as an electronic signature. *
Thank You!
We look forward to having your teen play on our team!
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