St. Patrick Catholic Church

Like the Apostles, we "recognize Him, Jesus,
in the breaking of the bread."

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Permission Form

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Event Permission Form
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- Relationship to Child REQUIRED Please fill out this field. Please enter valid data.
- 1. Consent:
- I grant my permission for my child REQUIRED Please fill out this field. Please enter valid data.
- to attend and participate in REQUIRED Please fill out this field. Please enter valid data.
- to be held at REQUIRED Please fill out this field. Please enter valid data.
- on REQUIRED Please fill out this field. Please enter valid data.
- 2. Student Cooperation:
  My child agrees to abide by all the rules of aforementioned Activity and to obey the staff in charge of this Activity. The Parish, School, and Diocese will not be liable for my child's failure to cooperate and/or abide by the rules. Any infraction of the rules may result in the immediate dismissal of my child from the Activity at my expense and without refund to me of the costs paid for the Activity.
- 3. First-Aid/Emergency Treatment:
  I authorize the School, Parish, and Diocese and its employees and volunteers to administer first-aid to my child if deemed necessary and appropriate to preserve the life, limb or well-being of my child. I authorize the Parish, School, and Diocese to contact and engage medical personnel and arrange for emegency treatment of my child, including transportation for medical, dental, surgical or hospital care or diagnosis, and I consent to that treatment for my child. I agree that I am financially responsible for such medical treatment.
- 4. Administration of Medication provided by parent/guardian of child:
  If my child needs to take prescription or non-prescription medication during this Activity, I have provided the medication in its orginal container. I give permission to an adult employee or adult volunteer to administer the medication or assist in the administration of the medication to my child in the dosage prescribed by the prescription or for non-prescription medication, the dosage recommended on the container by the manufacturer. If there are explict instructions for this medication, I state them here:
- Instructions for Medication
- 5. Release:
  I hereby release and discharge The Diocese of Rockford and its Bishop, and the Parish and School, and the officers, directors, employees and volunteers of same, from all claims for personal injuries or property damage that I or my child may suffer while my child is attending and/or participating in the Activity, unless the injuries or damage resulted from willful misconduct of the Diocese, the Parish, the School or its employees. If I have provided medication for my child to take during this Activity, I hereby release and discharge The Diocese of Rockford and its Bishop, and the Parish and School, and the officers, directors, employees, and volunteers of same, from all claims for personal injuries or property damage that I or my child may suffer as a result of the administration of or lack of administration of or assistance in or lack of assistance in the administration of said medication to my child, whether by my child and/or an adult employee and/or an adult volunteer; unless the injuries or damage resulted from willful misconduct of the Diocese, the Parish, the School or its employees.
- I agree and grant my permission Please select this field.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
- Student or Youth Emergency Information
- Parish/School/Diocesan Entity REQUIRED Please fill out this field. Please enter valid data.
- City/State REQUIRED Please fill out this field. Please enter valid data.
- Family Name REQUIRED Please fill out this field. Please enter valid data.
- Full Name of Child REQUIRED Please fill out this field. Please enter valid data.
- Sex REQUIRED Male Female Please fill out this field.
- Special Health Condition/Prescribed Medication or Dietary Needs
- Home Address REQUIRED Maximum 500 characters Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Name of Mother/Guardian REQUIRED Please fill out this field. Please enter valid data.
- Place of Employment REQUIRED Please fill out this field. Please enter valid data.
- Work Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Name of Father/Guardian REQUIRED Please fill out this field. Please enter valid data.
- Place of Employment REQUIRED Please fill out this field. Please enter valid data.
- Work Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- If divorced, name of legal custodial parent Please enter valid data.
- Do Mother and Father have Joint Custody? Yes No
- If custodial parent cannot be reached, may we contact non-custodial parent? Yes No
- Responsible Adult(s) who have agreed to assume responsibility for child, if parent/guardian cannot be reached.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Relationship to Child REQUIRED Please fill out this field. Please enter valid data.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Relationship to Child REQUIRED Please fill out this field. Please enter valid data.
- Physician of Choice REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Hospital of Choice REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- If I, or responsible adult, and physician of choice, as indicated above, cannot be reached in an emergency and immediate medical and/or hospital attention is indicated I hereby authorize the transporting of my child to a hospital or physician for treatment.
  I Agree Please select this field.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
Submit

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