Agrisano Permission Slip

I ask for and grant permission for my son/daughter _____________________________________to participate in an event that requires transportation to a location away from the parish. This activity will take place under the guidance and direction of employees and volunteers from ______St. Bridget______ (parish).
Event: Steve Agrisano Where: East Catholic High School When: March 9, 2008 - Confirmation Class Time of Event: Leave St. Bridget 6:15pm Return 9:00pm Mode of Transportation: Bus from St. Bridget parking lot Person in charge from parish: Eileen Carroll & Kathy Sinnamon	While youth are responsible for his/her own behavior, as parent and/or legal guardian, I remain legally liable for any actions or damages made by the above named minor. I am aware that I will be called if my teen breaks any of the rules and has to be sent home. I agree on behalf of myself, my teen named herein, our heirs, successors, and assigns to hold harmless and defend. St. Bridget (parish), its officers, directors, agents, employees, representatives associated with this event from any and all liability claims, loss or damage arising from or in connection with my teen attending this event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the above named parish, its officers, directors, agents, employees, or representatives associated with the event for reasonable attorney fees and expenses arising in connection therewith. I hereby warrant that to the best of my knowledge, my teen is in good health and I assume all responsibility for his/her health. In the event of an emergency and I can not be reached, I hereby give permission to transport my teen to a hospital or medical facility and to seek medical attention. I give permission for the administration of non-prescription medication - aspirin, throat lozenges or cough syrup - if deemed appropriate and if the situation is not life-threatening.
As the teen requesting permission to attend this activity, my signature below indicates that I am aware of my responsibility to actively participate and maintain the prescribed code of conduct for the safety and enjoyment of all.
Emergency contact person: Name _____________________ relationship ____________ phone_____________ Hospital Preference: Name ________________________________(town)______________________________ Doctor: Name __________________________________________(phone)_____________________________ Insurance: Company ____________________ Employer ________________ Group# _____________________ Subscriber name _________________________________ Subscriber # _______________________ Date of last tetanus shot: ___________________________________________ Medications currently taking:(name and dosage) ________________________________________________ Allergies: (medication, foods, plants, insects) ______________________________________________________ You should also be aware of these special medical/physical/mental conditions of my child (special diet, sleepwalking, fainting, nose bleeds, recent injuries, exposure to contagious diseases, etc):

Print name__________________________ Signature____________________________ Date_________
Student’s Name _______________________ Signature ___________________________________ Hit Counter