St. Anne/St. Matthew Youth Ministry

St. Matthew 105 Southville Rd Southborough MA 01772

St. Anne 20 Boston Rd Southborough MA 01772

Parent Guardian Release and Consent Form

Name of Youth: ___________________________________ Email: _______________________________

Parish: ___________________________________________ Town: _______________________________

Home Phone____________________________ Emergency(beeper cell phone)_______________________

Insurance Policy Name _____________________________ Policy # ______________________________

Please list allergies ______________________________________________________________________

Medications and dose ___________________________________________________________________

Medical Conditions (seizures, depression, diabetic etc) _________________________________________

_____________________________________________________________________________________

I, _______________________, give permission for my son/daughter,________________________________ to participate in (name of event)

on (date of event) __________. I am parent/guardian of my child authorized to sign this form. I, individually and as parent/guardian of my child, for ourselves and for our heirs, executors and administrators, hereby release and forever discharge The Roman Catholic Bishop of Worcester, a Corporation Sole, their agents, servants, employees, volunteers and priests from any and all claims and causes of action, including but not limited to claims for personal injury or property damage, which I, individually and/or as parent guardian of my child, may have arising out of or in any way related to the aforementioned trip. I also state that I am not aware of any health reasons which would prohibit or limit my child's participation in the event.

I give permission for my daughter/son to be transported in privately owned and/or public vehicles transportation to and from the ST. ANNE/ST. MATTHEW PARISH YOUTH MINISTRY EVENT.

In case of medical emergency, I understand that every effort will be made to contact the parent(s) or guardian(s) of my child. In the event that I cannot be reached, I give permission for my son/daughter to be evaluated, diagnosed, treated and/or medicated by licensed medical personnel. In addition, I give permission for the release of any medical records, which I have provided to ST. ANNE/ST. MATTHEW PARISH YOUTH MINISTRY, and participating parishes to medical personnel in case of illness.

o I hereby give permission for my son/daughter _________________________________ to be photographed during above mentioned youth ministry event and photos of my son/daughter may be used for private and public distribution, including the publications of photos in newspapers, newsletter, promotional literature, web pages, slide shows and other media.

o My daughter/son, ________________________________, may not be photographed.

Parent/Guardian signature: _________________________________ Date:____________