​STUDENT AND YOUTH ACTIVITY PERMISSION FORM​

LOCATION:                                                                                                                                                     

Minor's Name:                                                                                                                                                                                                                   

Address:                                                                                                                                                                                                                                      

Date of Birth:                                                

Male ______________ Female  _______________

Grade            

Activity:     Field Trip  X      

Retreat            

Other (specify)                                                                                                   

​Date(s) of Activity:                                                                                                                                            Cost (monies will be taken out of your FACTS Account):                                                                                           

Purpose:                                                                                                                                                                                                            

Description of Activity:    Drama Club Presentation of High School Musical, Jr.                  

See Attached:             

Mode of Transportation:    Walk           

Car Pool            

Bus            

Other (specify)                                               

Teacher/Adult Leader:                                                                                                

Attire:                                                            

I request that my son/daughter be permitted to participate in the above activity. My son/daughter has no medical condition that would render it inappropriate for him/her to participate in this activity.

My son/daughter has no known medical needs, allergies or dietary restrictions except as follows:                       

Should it be necessary for my son/daughter to take medication while participating in this activity, I hereby give my son/daughter permission to self-administer his/her medication in accordance with the Medication Authorization and Permission Form, and, if my son/daughter cannot self-administer, I give permission to the responsible staff members or chaperones to administer or to assist in the administration of my son/daughter's medication. I also give permission to the responsible staff members, chaperones, medical practitioners and medical facilities to use their judgement in obtaining and providing medical treatment for my son/daughter should it become necessary to do so. I agree to relieve the Location and participating adults from liability in connection with this request. I understand that the insurance benefits through the Location, if any, may have limited application, and that I am entirely responsible for the cost of all medical treatment provided to my son/daughter. I agree to indemnify and hold the Location harmless from the cost of any medical treatment and related expense and cost incurred.

Release of Liability: As a condition of participating in this activity, I hereby hold harmless, release and discharge The Roman Catholic Archbishop of Los Angeles, a corporation sole, Archdiocese of Los Angeles Education & Welfare Corporation and the Location, their respective agents and employees and any parent/volunteer/ chaperone, from any and all liability, loss or claims for personal injuries, wrongful death or property damage that I or my son/daughter may suffer as a result of participation in the activity described above.

Parent/Guardian       PRINT ______________________________________    /   SIGN  ___________________________________                              Date  ______________________

Home Phone  _________________________                                  Cell Phone  _______________________________                                       Work Phone  ________________________

Person to Notify in case of Emergency if Parent or Guardian is unavailable:

ame:                                                                                                                         Phone:                                                               

Health Insu​rance Company:                                                                               Policy No.:                                                        

​Copyright © 2015 Roman Catholic Archbishop of Los Angeles, a corporation sole. All rights reserved.  ~ Page 1 of 1 w Revised 06-2015/08-2017/11-2019​

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