CTEC BLAST Event Parental Permission Form
Each participant(s) must have this digitally signed by a parent or guardian for the Spring2025 event. If a field does not apply to you or your children, you can mark it as not applicable.
Sign in to Google to save your progress. Learn more
Email *
Catholic Teens Encountering Christ-BLAST Events will take place under the guidance and direction of St. Mary Cathedral/St. Ann Pastorate & St. Boniface/St. Lawrence pastorate employees and/or volunteers from the Diocese of Lafayette-in-Indiana.   

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above-named minor (s) (“participants”).  I agree on behalf of myself, my child/children named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Mary Cathedral, St. Lawrence Church, St. Boniface, St. Thomas, St. Anne's, Blessed Sacrament  & St. Lawrence its officers, directors, employees and agents, and the Diocese of Lafayette-in-Indiana, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending one of the following events or in connection with any illness or injury (including death) or cost of medical treatment in connection there with, and I agree to compensate the parish/school, its officers, directors and agents, and the Diocese of Lafayette-in-Indiana, its employees and agents and chaperons, or representative associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish or the Diocese of Lafayette-in-Indiana.
First Participant's First & Last Name (You can enter additional students from your family attending below ) *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Event:   Bowling
Date:  4-6-2025
Estimated time of event:   6:30-8:30p
Organized by:  Bill & Sue Bayley
Student #2 Name
Student #2 Date of Birth
MM
/
DD
/
YYYY
Student #2 Gender
Event:   Bowling
Date:   4-6-2025
Estimated time of event:   6:30-8:30p
Organized by:  Bill & Sue Bayley
Student #3 Name
Student #3:  Date of Birth
MM
/
DD
/
YYYY
Student #3 Gender
Event:   Bowling
Date:   4-6-2025
Estimated time of event:   6:30-8:30p
Organized by:  Bill & Sue Bayley
Student #4 Name
Student #4:  Date of Birth
MM
/
DD
/
YYYY
Student #4 Gender
Event:   Bowling
Date:   4-6-2025
Estimated time of event:   6:30-8:30p
Organized by:  Bill & Sue Bayley
Parent/Legal Guardian's name: *
Home Address *
Mobile Phone *
Work Phone *
Date *
MM
/
DD
/
YYYY
*Digital Signature *
MEDICAL MATTERS: I hereby warrant that to the best of my knowledge, my child/children is in good health and I assume all responsibility for the health of my child/children. (Of the following statements pertaining to medical matters, sign only those that are applicable.)

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child/children to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Name & Relationship *
Phone: *
Family Doctor *
Phone *
Family Health Plan Carrier *
Policy# *

*Digital Signature

*
Phone *
Medications: My child/children is taking medication at present. My child/children will bring all such medications necessary and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are as follows
*Digital Signature *
No medication of any type, whether prescription or non-prescription, may be administered to my child/children unless the situation is life-threatening and emergency treatment is required.
*Digital Signature
-OR-
I hereby grant permission for non-prescription medication (i.e. non-aspirin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child/children, if deemed appropriate.
*Digital Signature *
Specific Medical Information: The parish/school will take reasonable care to see that the following information will be held in confidence.
Allergic reactions (medications, foods, plants, insects, etc.): *

Immunizations (Date of last tetanus/diphtheria)

*

Does your child/children have a medically prescribed diet?

*
Does your child/children have any physical limitations? *
Are any of your listed children subject to emotional reactions to new situations? (Example: fainting) *
Has any of your listed children recently been exposed to a contagious disease or conditions, such as mumps, measles, chicken pox, covid, etc.? If so list date and disease or condition: *
You should be aware of these special medical conditions of my child/children: *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of St. Lawrence Catholic Church.

Does this form look suspicious? Report