RELIGIOUS EDUCATION PROGRAM

DIOCESE OF ERIE/ST. LEO'S PARISH RELEASE FORM

FOR SCHOOL YEAR 2009 ~ 2010

For classroom activities, retreats, field trips, social events, service projects

PLEASE MAKE FEE PAYABLE TO "ST. LEO'S"  One Child $35, Two Children $50, Three or More $75.

Student's Full Name: 

Address: 

Grade:      Phone: 

Family Physician:     Phone:   

Family Heath Insurance Company: 

Policy No. (individual):      Group No.: 

Please list any health information that might be needed by St. Leo's Religious Education and Youth Ministry staff, parental aides, or health emergency personnel:  (allergies, chronic conditions, recent or current injuries or illness):

It is the responsibility of the parents to immediately notify the Religious Education Coordinator or the Youth Ministry Supervisor of any allergies or dietary restrictions their child may have.  Neither the Religious Education Coordinator, nor any catechist, youth ministry leader or volunteer may administer medications to the children.

Please list other person(s) we may call for advice or direction in caring for your child in the case of a serious accident, illness, operation or disaster warning.

Name: 

Phone:   Address:         PLEASE NOTE THAT THIS INFORMATION IF VITAL

Name: 

Phone:   Address: 

PERMISSION

I/we the parent(s)/guardian(s) of , request that St. Leo's Parish allow my/our son/daughter to participate in the classroom events, field trips, social events and service projects of the St. Leo's Religious Education and Youth Ministry functions in the 2009-2010 School Year.

MEDICAL AUTHORIZATION

In the event of injury or illness to our/my child during his/her participation in the Religious Education and Youth Ministry functions, if the parents/guardians or other persons specifically designated on the Registration Form cannot be reached, we/I hereby give our/my permission to the supervising adult for the necessary medical treatment to be given to our/my child.  We for ourselves/myself and for our/my child, our/my respective heirs, and our/my respective legal representatives so hereby indemnify and hold harmless any representative of the Diocese of Erie and the supervising adults from St. Leo's Parish from any and all claims, demands and causes of action of whatever kind and nature for their actions taken pursuant to this authority.  I/we agree that in case of injury to our/my child, we will apply our/my hospitalization and/or accident insurance toward the payment of the expenses incurred.

INDEMNIFICATION

I/we, hereby release and save harmless St. Leo's Parish and the Diocese of Erie, their agents, successors, legal representatives and any and all of its employees from any and all liability for any and all harm arising to my/our son/daughter as a result of his/her participation in the above-mentioned Religious Education and Youth Ministry activities at St. Leo's Parish.

Father's/Guardian's Signature:________________________________________Date:________________

Father's Full Name    

Address:     

Day Phone:       Evening Phone: 

Registered Member of St. Leo's Parish:  Yes       No 

Mother's Signature:_________________________________________________Date:________________

Mother's Full Name    

Address:     

Day Phone:       Evening Phone: 

Registered Member of St. Leo's Parish:  Yes       No 

CODE OF BEHAVIOR

Each youth must attend all of the scheduled activities that he/she agreed to attend.  The behavior of all must reflect Christian values.  The supervising adult will stay at the entire event and is responsible for his/her youth.  Drugs/Alcohol are not permitted.  I/we agree to cooperate with the adult supervisor's of the activity in which the youth is participating.  I/we have read and agree to uphold the above "Code of Behavior".

Student's Signature:________________________________________________Date:________________

Father's/Guardian's Signature:________________________________________Date:________________

Mother's Signature:_________________________________________________Date:________________

Click on the (Create printable form button above), this will finish your registration form, then print it out.
Please mail it in as soon as you can, we would like everyone registered before September 1st.