PARENTAL REQUEST FOR PARISH YOUTH EVENTS

EVENT:  Skating @ United Skates of America           COST:  $6pp includes skate

                5121 Armenia Ave.   Tampa, FL  33603                       rental, pizza, a drink.

DATE(S):  Wed, July 13, 2011                                                        TIME:  6:30- 9 PM

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 skating rink, don’t meet at St. Tim’s.  The address for the rink is 5121 N Armenia Ave., Tampa, 33603.  A signed permission slip is required.  Bring a little extra money for food & arcade.

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 the skating rink.

Parent/Guardian: _________________________________________________________Date: ____/_____/_____

(Signature)