Mission Trip 2019 Permission Form

Name*
First Last
Age at time of camp*
School Grade for 2019-2020*
Sex:*
- M
- F
Address*
Street Address City State ZIP Code
Home Phone*
Teen Cell*
Teen Email*

Parent Name(s)*

Parent Email*
Parent Cell*
Parent Cell*
T-shirt size*
PERMISSION & AUTHORIZATION FORM FOR MEDICAL TREATMENT
I/We, the parent(s) of the above teen request that Holy Family Teen Faith program allow my/our child to participate in Catholic Heart WorkCamp Summer Mission Trip in Huntingburg, IN July 14-19, 2019

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.
Family Physician*
First Last
Phone Number*
Name of Insurance Co.*
Policy Number*
Person to contact in case of emergency (if unable to reach parent):
Name/Relationship*
Phone Number*
Specific medical allergies, chronic illnesses and other conditions. Please list any & all medications that your child may take during the trip.
- I understand that a minimum of a $100 nonrefundable deposit is due at the time of registration or my son/daughter’s spot will not be held.
- I understand that if my son/daughter cancels after May 1st that I am still responsible for the entire fee and agree to pay the final balance of this trip by April 1, 2019.
Parent/Guardian Signature*
Date
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

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