FLAME II Retreat Permission Form

I/We, the parent(s) of
Name*
First Last
request that Holy Family Teen Faith program allow my/our child to participate in

Event: FLAME II Retreat
When: January 25-26, 2020
Place: Holy Family Parish, Inverness, IL

I hereby release and indemnify Holy Family Parish, its staff and its volunteers and the Catholic Bishop of Chicago, a corporation sole, from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in this event.

In the event that the undersigned or my (our) authorized physician, cannot be reached, and in the judgment of a responsible person accompanying the group, or other appropriate staff member, there is a necessity for immediate examination and/or treatment of my (our) child, I/We hereby authorize any of the aforesaid people to obtain for my child such medical services as are deemed necessary.

If attending Make-Up date on February 16th, please contact Grant directly by email.
Home Phone Number*
Other number (if applicable)
Family Physician*
Phone Number*
Name of Insurance Co.*
Policy Number*
Person to contact in case of emergency (if unable to reach parent):
Emergency Contact Name/Relationship
Emergency Contact Phone
Parent(s) Name(s)
First Last
Specific medical allergies, chronic illnesses and other conditions. Please list any & all medications that your child may take during the retreat.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.