CHRIST THE KING YOUTH GROUP



CHRIST THE KING YOUTH GROUP

PERMISSION FORM/MEDICAL RELEASE FORM/CONSENT AND WAIVER OF LIABILITY

Bike Trip September 15, 20007

Please complete this form using blue or black ink, and print

PARTICIPANT’S NAME: ____________________________________________

(FIRST) (MIDDLE) (LAST)

HOME ADDRESS : _____________________________________________

________________________________________________________________________

(Include City and Zip Code)

Names of Parents/Guardians: ______________________________________

Number to call for emergency: ______________________________________

Cell Phone(s): ___________________________________________________

Insurance Company: ______________________________________________

Policy Holder’s Name: ____________________________________________

Relationship to Policy Holder:_________________________________

Policy Number: _____________________________________________

In case of an emergency and parents cannot be reached, contact:

(Name) (Phone Number(s)) (Relationship)

Medical Information (Attach a separate sheet if necessary.)

1) List all allergies your child has: _____________________________________

2) List all medications your child will have with him/her and directions for taking it: ________________________________________________________________

In the event of an emergency, I hereby give authority to the accompanying adults (Patti Smith or Charles Goolsby), to authorize emergency medical treatment for my child. I understand that an attempt to notify me will be made before treatment is authorized.

PARENT/GUARDIAN SIGNATURE:

________________________________________DATE___________________

I/We hereby grant permission for our son/daughter _________________________to

participate in the Bicycle trip on Saturday, September 15, 2007. I/We understand

that transportation for this event will be by private automobile with Virtus-trained

adults present in each vehicle and by shuttle provided by the bike shop, Adventure

Damascus. I/We further understand that biking is an inherently

dangerous activity that can result in serious injury or death. As parent/legal

guardian, I/We remain legally responsible for any personal action(s) taken by my

/our child. I/We hereby state that I/we will hold harmless the Parish of Christ the

King Catholic Church and the Diocese of Richmond, as well as their officers,

directors, agents, chaperones, or representatives associated with this event, from

any injury arising from or in connection with my/our child attending this event,

including but not limited to accidents/emergencies, and/or the exposure to reckless

conduct of other persons. I/We hereby expressly waive any claims I/We may have or

ever have against the hosts and chaperones, the parish of Christ the King, and the

Diocese of Richmond arising from, related to, or associated with my/our child’s

participation in these events.

PARENT/GUARDIAN SIGNATURE(S):

DATE:________________________________

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