ST. VINCENT de PAUL
PARENT/GUARDIAN CONSENT FORM AND LIABILITY WAIVER


Participant's name: __________________________________________________________________________________
Birth Date: __________________ Sex ____________________ Grade: __________ Member or Guest: ______________
Parent/Guardian's name: _____________________________________________________________________________
Home Address: _____________________________________________________________________________________
Home Phone: ________________________________________ Business Phone: _________________________________
Would you be willing to help chaperon?   (Please circle):	Yes		No		Maybe

	Date/Type of event: ____________________________________________________________________
	Destination: __________________________________________________________________________
	Individual(s) in charge: _________________________________________________________________
	Estimated time of departure and return: ____________________________________________________
	Mode of transportation to and from event: __________________________________________________
	Student cost, if applicable: ______________________________________________________________


I, ______________________________________, grant permission ____________________________________________
	Parent/Guardian Name								Child's Name
to participate in the above named activity, and I warrant that my child is in good health.  In consideration of my child's participation, I agree to indemnify the Church of St. Vincent de Paul and the Archdiocese of St. Paul/Minneapolis from any claims or lawsuits brought against the Church of St. Vincent de Paul/Archdiocese of St. Paul/ Minneapolis by myself, my child, or others, that arises out of any behavior by my child at the event/activity described above.  I also agree to pay reasonable attorney's fees or expenses incurred by the Church of St. Vincent de Paul and Archdiocese in defense of such a claim/lawsuit.

EMERGENCY MEDICAL TREATMENT.  In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment.  I wish to be advised prior to any further treatment by a doctor or hospital.  In the event of an emergency, if you are unable to reach me at the above numbers, contact:
__________________________________________________________	__________________________________
			(Name)								(Phone)


OPTIONAL MEDICAL INFORMATION:
Medication my child is taking at present: _________________________________________________________________
Family health plan carrier number: ______________________________________________________________________
Family Doctor: _____________________________________		Phone Number: ____________________________

As parent or guardian, I agree to all of the above stated considerations and conditions.
________________________________________________________		__________________________________
			(Signature)							(Date)

reforms\jr sr consent form