CTEC BLAST Event Parental Permission Form
Each participant  must have this digitally signed by a parent or guardian.
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Participant's Name  *
Participant's #2 Name 
Participant's #3 Name 
Participant's #4 Name 
Date of Birth
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Student #2:  Date of Birth
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YYYY
Student #3:  Date of Birth
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Student #4:  Date of Birth
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Parent/Guardian's name: *
Home Address *
Home Phone
I grant permission for my child/children to participate in this parish event. This activity 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.  A brief description of the activity follows:                                                           Type of event: Catholic Teens Encountering Christ-Blast Events                                                Date of events: School year 2022-2023                                                                                                                                        
Destination of event: Various Venues in Lafayette, IN                                          Individuals in charge: Sue and Bill Bayley                                                                Estimated time of event:   4-7pm-10:00pm                                                            
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“participant”).  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. Lawrence its officers, directors, employees and agents, and the Diocese of Lafayette-in-Indiana, its employees and agents, chaperons, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, 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.
*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:
*Digital Signature *
Family Doctor *
Family Health Plan Carrier *
Policy# *
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.):
Does child have any physical limitations?
You should be aware of these special medical conditions of my child:
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