Eucharistic Youth Rally
“Fired Up”
November 3rd & 4th, 2007
Youth Permission

Parish:                                                                                                                                     

Name:                                                                                                  Age:                                       

Address:                                                                                                                                  

Phone Number:                                                  Cell Number:                                                   

Date of Birth:                             Insurance Carrier:                                                                  

Medication & Reason for:                                                                                                         

Physician’s Name & Phone Number:                                                                                        

Any Medical History:                                                                                                                

Allergies_________________________________________________________________

Dietary Needs:                                                                                                                         

Emergency Contact:                                                      Relationship:                                         

Emergency Phone Number:                                                                                                      

Parent Email Address:                                                                                                              

          The undersigned do hereby release, forever discharge and agree to hold harmless The Diocese of Buffalo, St. Mary of the Angels Parish and Archbishop Walsh High School from and against any and all liability, claims,  demands, lawsuits and expenses of any kind whatsoever which may be incurred or suffered by the undersigned and/or participant (if participant is 18 or under, 18 or older) while attending the Eucharistic Youth Rally at Archbishop Walsh High School .

             The undersigned further agree to indemnify and hold The Diocese of Buffalo, St. Mary of the Angels Parish and its respective member, directors, employees and agents (collectively, the “Indemnities,”) harmless from and against any and all claims, demands, actions, lawsuits, and liabilities, including attorney fees and expenses and costs sustained by the Indemnities as a result of negligent, willful or intentional acts of the undersigned and/or participant (if participant is 18 or under, 18 or older).

             I hereby give permission to St. Mary’s Parish and its respective staff and adult volunteers to take said participant to a doctor or hospital and herby authorize medical treatment, including but not limited to emergency surgery and I (we) fully and completely assume all responsibility for all medical bills.  Further, should it necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I (we) assume all responsibility and transportation costs.  This authorization also permits my youth to receive such treatment only after such a reasonable effort has been made to reach me.  Further, should it be necessary for all participants to return home due to medical reasons, disciplinary action or otherwise, I (we) assume all responsibility and transportation costs.

            In signing this I am granting my youth permission to stay overnight at Archbishop Walsh High School .  In signing this I am granting my youth permission to be transported in privately owned vehicles to and from the event.  As well I am aware of the rules and responsibilities that my son/daughter is expected to uphold and respect.

Rally Photography/Video Release

 I                                                                                 parent/guardian of                                                                                            

understand my son/daughter’s photograph and/or likeness and name may be used in a future promotion by St. Mary of the Angels.

 Youth Signature:                                                                                                                   Date:                                                     

 Parent Signature:                                                                                                                   Date:                                                     

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ryan@saintmaryoftheangels.org
www.saintmaryoftheangels.org
Mail forms to:
Debbie McPherson
Youth Rally
601 West Henley St.
Olean, NY 14760

 With a $25.00 Check
                                                                                                                                                                                                               

RALLY USE ONLY

                 Permission Slip – Youth

                 Sleeping Room Assignment

                 Check/Money Order Number