St.

Andrew Church
Archdiocese of San Francisco Parental Permission Form Activity

Form and payment due no later than August 3rd. $35 St. Andrew Parishioners $40 others

Summer Youth Retreat will take place from Saturday, August 10th to Sunday, August 11th, 2011. Students will assemble on Saturday morning at 10 AM at St. Andrew Parish Hall. The retreat will take place at the parish hall and will conclude on Sunday evening at 8 PM. Birth date ______________________

Student's Name ____________________________________

Address ____________________________________________________________________________ Parent/Guardian's Name _______________________________________________________________ Address ____________________________________________________________________________ Home Phone: _____________________________Work Phone: ______________________________

Person to notify in an emergency if parent is not available: Name _______________________________________________________ Relationship to student________________________________ Phone __________________________ The following person (if not the parent) will pick my teen up on Sunday evening. Name: _____________________________________________ I, the parent (guardian) of the above named student, hereby give my permission for his/her participation in the activity named above. I agree to direct my student to cooperate and conform with the directions and instructions of the parish, school, or Archdiocesan personnel responsible for the activity. I agree that in the event my student is injured as a result of his/her participation in the above named activity, including transportation to and from the activity, whether or not caused by the negligence (active or passive) of the parish/school or Archdiocesan youth activities program, or any of its agents or employees, recourse for the payment of any resulting hospital, medical or related costs and expenses will first be had against any accident, hospital or medical insurance or any available benefit plan of mine or my spouse. Except as noted below, I am not aware of any medical condition of my student which would render it inappropriate for him/her to participate in the above activity. I hereby give permission to the physician selected by the youth activities supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician. Parent/Guardian's Signature __________________________________Date ______________________ Other Parent/Guardian Signature ______________________________ Date _____________________