By checking this box, I hereby certify that the above information is correct and give permission for my child to be transported in privately owned vehicles to and from public transportation or for approved out-of-program activities; and for the release of medical records to an attending physician in case of illness. In case of medical emergency, I understand that every effort will be made to contact parents or guardian of participants. In the event that I cannot be reached, I hereby give permission to the physician selected by the Program Director to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child, as named herein.

This activity will take place under the guidance and supervision of adult chaperones. As parent, or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by the child. If you would like your child to participate in this event, please complete, sign and return the following statement of consent and release of liability. As parent, or legal guardian, you remain fully responsible for any legal responsibility, which may result from any personal actions taken by the named child. I hereby consent to participation by my child in the event described above. I understand that this event will take place away from parish grounds and that my child will be under the supervision of the designated supervisor on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation. I give my permission for my child, in case of an emergency, to be taken to a physician or hospital by either the supervisor in charge or by an adult chaperone. I understand that every effort will be made to contact me. If I cannot be reached, however, I hereby give permission to the physician selected by the supervisor in charge or adult chaperone(s) to hospitalize and secure proper treatment (including surgery) for my son/daughter. The cost of any necessary medical care or treatment for my son/daughter will be my expense. If your youth brings or uses any drugs, alcohol, weapons, or tobacco products or engages in reckless or violent behavior, you will be expected to retrieve your son/daughter from the trip immediately. Authorities may be notified. Photographs or videotape of participants may be used in publications, websites, or other materials produced from the Office of Youth Ministry or the Diocese of Charlotte.