Diocese of Palm Beach Activity Release Form
Participant Information
Name:______________________________________________ Phone:____________________
Street: ______________________________________________________________________
City: __________________________State: ____ Zip: _______ E-mail: _____________
Mother's Name: _________________________ Father's Name: ______________________
Parent's address (if different from your own)
Street: ______________________________________________________________________
City: ____________________________________________ State: ____ Zip: __________
Insurance Company: ________________________________ Policy No.: ______________
Activity Information
Parish: ______________________________________________________________________
Activity:
Place:
Date of Activity:
Adult Chaperone: __________________________________ Phone: ___________________
Permission and Medical Treatment Waiver
I, ___________________________, the parent/guardian of _______________________
do hereby give my permission for him/her to attend the above activity and to be
treated for a medical emergency in my absence while participating in the Youth
Ministry program. The Youth Minister or Adult supervisor may act as an agent
in my absence. In case of accident, I do not hold the Diocese of Palm Beach,
the parish, its staff, or the adult chaperones responsible.
In case of emergency, if I am not available at the above address and phone,
please contact:
Name: ____________________________________________ Phone: _____________________
Parent/Guardian Signature: __________________________________ Date: ___________
Special Dietary Needs: ________________________________________________________
Allergies:_____________________________________________________________________