PARENTAL REQUEST FOR PARISH YOUTH EVENTS

EVENT:  Movie theater night@                                       COST: whatever movie ticket, &

              Veterans – July 6, Citrus Park Mall Aug 3           what you want to eat/drink costs?

DATE(S):  Wed, July 6 and Aug 3^rd, 2011                     TIME:  6:30- 9 PM range for movie

PARISH/SCHOOL/SPONSOR:  St. Timothy Youth League

INFORMATION ABOUT MY YOUTH

NAME OF YOUTH_____________________________DATE OF BIRTH___/___/___

HOME ADDRESS_____________________________________________________

NAME OF PARENT/GUARDIAN__________________________________________

HOME PHONE (   )_____________________CELL PHONE (   )_________________

MEDICAL INFORMATION:  Please list all information pertaining to allergies, diet, special medication, health conditions or any other information necessary in an emergency situation.  Explain fully.___________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

PLEASE NOTE:  Meeting directly at the Theater, don’t meet at St. Tim’s.  The address for the Veterans Theater is 9302 Anderson Road Tampa, FL 33634.  Citrus Theater is at that Mall.  A signed permission slip is required for safety.  Be sure to bring at least $10 for ticket, more if must eat too.

CONSENT AND RELEASE

General: I hereby request and give my permission for my youth to participate in the above event. I understand and assume the risks inherent with this event from other parties, but I also understand that all reasonable care and supervision will be exercised to provide for the general well-being of my youth. I, individually and on behalf of my youth named below, do hereby release, covenant not to sue, and save harmless: The Most Rev. Robert N. Lynch, Bishop of the Diocese of St. Petersburg; the above parish/School; and all employees, agents and volunteers for the event, from any and all claims for any and all harm arising to my youth as a result of their participation in this event.

Medical: I request the Parish/School representative obtain medical treatment for my youth in the unlikely event of injury or illness during this event and I agree to pay any expenses incurred for such treatment.

Transportation: Transportation is to be provided by parents.   We will meet at theTheaters.

Parent/Guardian: _________________________________________________________Date: ____/_____/_____

(Signature)