PARENTAL REQUEST FOR PARISH YOUTH EVENTS

EVENT:  Q-Zar Lazer Tag                        COST:  $15 (includes 2 Lazar Tag games, 2 Slices

 Pizza & unlimited soda)

DATE(S):      Wed, July 20                        TIME:  6:30-9:00 PM

PARISH/SPONSOR:  St. Timothy Youth Ministry

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:  Parents need to provide transportation to and from Q-ZAR on

7807 N. Dale Mabry TPA 33614.  Bring additional money to play other video/DDR air hockey and games, while we wait our turn at Lazar tag.

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:  To be provided by parents.

Parent/Guardian: _________________________________________________________Date: ____/_____/_____

(Signature)