Middle School & High School

Participant’s Name: _________________________________________

Parent/Guardian’s Name: _____________________________________

Home Address: _____________________________________________

Home Phone: ________________ Business Phone: ____________

I grant permission for my child ________________________ to participate in this parish event that requires transportation to a location away from the parish site. This activity will take place under the guidance and direction of parish employees and/or volunteers from Sacred Heart Parish and the Archdiocese of Anchorage.

Type of event: Junior High Winter Blast

Date and estimated length of event: December 10, 2005  8:00 am to 7:00 pm

Destination of event: Sacred Heart Parish -- Holy Family Cathedral -- Dimond Center Cinemas --                                                                             Sacred Heart Parish

Individual in charge: Karoline Dhuyvetter, Gretchen Morava, Julie DeKreon

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 named herein, or our heirs, successors, and assigns, to hold harmless and defend Sacred Heart Parish, its officers, directors and agents; and the Anchorage Archdiocesan chaperones or representatives associated with the event, arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the parish, Its officers, directors and agents and the Anchorage Archdiocesan, chaperone or representative associated with the event for reasonable attorney’s fees and expenses arising in connection therewith.

Signature: _____________________________ Date: ________________

• I have an Emergency Treatment Form on file in the Parish office.

 Medical Permission to Treat

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

Emergency Medical Treatment

In the event of an emergency, I hereby give permission to transport my child 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 number ____________________

Family Health Plan Carrier _________________________

Policy Number  _____________________________

My child is taking the following prescription medications:

My child has allergies to the following medications, foods, plants, insects, etc.)