LITTLE FLOWER’S YOUTH MINISTRY

NET RETREAT PERMISSION

Name:     ________________________________________________                Age:  _______

Phone #:  ______________________________________

Address:  ___________________________________         Town:  ________    Zip:  ____________

Parish:  ___________________________________         Date of Birth:  _____________________

School:  ______________________________________________     Grade:  ____________

Is your son/daughter on any medication?  YES_______                             NO______

If yes, please describe the kind of medication, dosage, frequency & administration by whom authorized.

_______________________________________________________________________________________

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EMERGENCY CONTACT:

Name:     ________________________________________                Phone #:  ________________

Address:  __________________________________         Town:  ________    Zip:  ____________

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I give permission for my child to participate in Little Flower’s Youth Ministry Net Retreat held at

Our Lady of Lourdes in Mountainside, New Jersey on May 5, 2010.

I hereby waive and release any and all rights claims or damages which I may have against Little Flower’s Parish, the Archdiocese of Newark C.Y.O./Youth Ministries, and all of their agents, servants and employees, for any and all injuries which my child may incur while taking part in your program.  This release also encompasses any injuries which may be sustained while traveling to and from participation in your program.  As a Parent/Guardian I understand it is my responsibility to pick up my child at the predetermined time.  I also understand that if my child becomes ill or destructive, the above “EMERGENCY CONTACT” will be called to take my child home.

_______________________________________________                  __________________

Parent/Guardian Signature                                                                                              Date

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I hereby waive and release any and all rights claims or damages which I may have against Little Flower’s Parish, the Archdiocese of Newark C.Y.O./Youth Ministries, and all of their agents, servants and employees, for any and all injuries which I may incur while taking part in your program.  This release also encompasses any injuries which may be sustained while traveling to and from participation in your program.  I also understand that if I become ill or destructive, the above “EMERGENCY CONTACT” will be called to take me home.

_______________________________________________                  __________________

Signature of Participant                                                                            Date