Charlotte Diocese Field Trip Release Form

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St. Matthew Catholic Church - LIFE TEEN Bowling @ Sports Connection

Dear Parent or Legal Guardian: Your son/daughter, guardianship is eligible to participate in a Diocesan-sponsored activity that requires personal transportation to locations away from your home site. This activity will take place under the guidance and supervision of adult chaperones. A brief description of the activity follows:

DATE OF ACTIVITY: Sunday, Feb. 9, 2020

Drop-off at 6:30pm and Pick-up at 9pm at Sports Connection

ACTIVITY: SPORTS CONNECTION - BALLANTYNE

Bowling

ADDRESS: 11611 Ardrey Kell Rd, Charlotte, NC 28277

DESIGNATED SUPERVISOR OF ACTIVITY: Youth Ministers and Chaperones

If you would like your child to participate in this event, please complete this form and agree to the following statement of consent and release of liability. As parent, or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by the named child.

I/We, *

Parent(s)/Guardian(s)

hereby consent to participation by my child, *

Name of Participant

in the event described above. I understand that this event will take place away from parish grounds and that my child will be under the supervision of the designated supervisor on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation. I give my permission for my child, in case of an emergency, to be taken to a physician or hospital by either the supervisor in charge or by an adult chaperone. I understand that every effort will be made to contact me. If I cannot be reached, however, I hereby give permission to the physician selected by the supervisor in charge or adult chaperone(s) to hospitalize and secure proper treatment (including surgery) for my son/daughter. The cost of any necessary medical care or treatment for my son/daughter will be my expense. *

I Agree

Required

PARENT CONTACT INFORMATION:

Primary Phone Number: *

Secondary Phone Number

Email: *

Accident/Hospitalization Policy Name: *

Policy number: *

Parent/Guardian: *

Date: *

YYYY

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