Activity: Travel to:
*Leaving from Blessed Sacrament Catholic Church at
*Returning to Blessed Sacrament Catholic Church at
Means of Transportation: Parish Van and Private Vehicles
Adult in charge:
Cost:

I give permission for _________________________ to attend and fully participate in the THS activity which is sponsored by Blessed Sacrament's Catechetical Ministries Dept. I also authorize any emergency facility to administer any emergency first aid and/or medical treatment that may be required for my son/daughter and I accept any and all liability for any such treatment and related expenses.

I further release holding the Community of the Blessed Sacrament, Teens in the Holy Spirit,the Diocese of Phoenix, the Diocesan Priests or any adult working with the youth responsible or liable for anything which may arise as a result of any injury he/she may sustain on the way to, during, or leaving this activity.

Signed_____________________________date_________________
home address_______________________home phone__________________
Physician__________________________phone__________________
Insurance Co.______________________policy#__________________
Policy in the name of______________________
Please list any medications, allergies, or other health concerns_________________________________________________________
_____________________________________________________________
_____________________________________________________________
Check here if your youth can be given Tylenol____