ST MARGARET CHURCH / ST MARY MAGDALEN  MISSION
The Archdiocese of Baltimore & The Division of Youth and Young Adult  Young Adult Ministry
PARENTAL AGREEMENT & PERMISSION FORM*

Name of Youth ________________________________________________________ Home Phone: ___________
Parent (s) Name: ________________________________________________________Work Phone: ___________
Other Phone # where Parent can be reached ___________________________________Date of Birth: ___________
Address: _________________________________ City/State/Zip: ______________________________________
Social Security # ________________________________________________        Male     Female    (please circle)    
In consideration of the wholesome recreational and learning experience in which my son/daughter will participate, I as parent or guardian
of my son/daughter, do hereby agree to allow my son/daughter to accompany the youth ministry group of this Parish to: (event) _____________________________________________________________________________   (the program), located at _______________________________________, meeting from___________________________ (start date/time) to
________________________________ (finish date/time).
I/we  acknowledge receipt of the information sheet describing the planned activities.

        In consideration of the opportunity for my son/daughter to participate in this program, I agree to release and hold harmless and indemnify St. Margaret's Roman Catholic congregation, Inc.  (the Parish of  St. Margaret/St. Mary Magdalen), the Division of Youth and Young Adult Ministry, the Roman Catholic Bishop of Baltimore and his successors, a Corporate Sole, and all their agents, servants, and employees from any liability, claims, demands, and causes of action arising out of or relating to any loss, damage or injury sustained in connection with or arising out of my son/daughter's participation in this program. 
         I hereby grant permission to any staff person to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that I cannot be reached.

PLEASE CHECK ONE OF THE FOLLOWING
[     ]     I am covered by hospitalization and medical insurance under policy # _____________________________
            issued by ______________________________________________________________________________
[     ]     I do not have medical coverage and assume responsibility for the cost of hospitalization and medical care for my
             son/daughter.
                        Witness our hands and seals this ______ day of _______________, 200___.

    I hereby grant permission to any staff person to provide the following over-the-counter drugs to my son/daughter
    if  requested by my son/daughter  (please circle those which apply).

          Tylenol        Benadryl        Advil        Sudafed        Midol        Kaopectate        Neosporin       Pepto Bismol

ADD any other medical information concerning medication, allergies, illness, etc. along with any dietary restrictions
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Parent/Guardians of participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Division of Youth and Young Adult Ministry, the Archdiocese of Baltimore, or the Parish of St. Margaret/St. Mary Magdalen. (Participants would not be identified, however, without specific written consent.) Parents/Guardians who do not wish their child(ren) to be photographed or filmed should so notify the Division in writing. Please note that the Division has no control over the use of photographs or film taken by media that may be covering the event in which your child(ren) participate (s).

Parents / Guardians of participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by the Division of Youth and Young Adult Ministry, the Archdiocese of Baltimore, or the Parish of St. Margaret / St. Mary Magdalen.  (Participants would not be identified, however, without specific written consent.)  Parents / Guardians who do not wish their child (ren) to be photographed or filmed should so notify the Division in writing. Please note that the Division has no control over the use of photographs or film taken by media that may be covering the event in which your child (ren) participate.

* At least One Parent Signature is required along with the signature of the Youth Participating. Youth signature indicates agreement with  Code of  Behavior shown below.

Parent/Guardian Signature _____________________________________________ Date ___________________

Parent/Guardian Signature _____________________________________________ Date ___________________

Youth Signature _____________________________________________________ Date ___________________

CODE OF BEHAVIOR

It is great having you attend this trip. The following guidelines will ensure a safe and mannerly experience for
all of us participating in this activity.

1. You are expected to remain with your group and follow the guidelines specified for this activity.

2. The possession of alcohol or illegal drugs is clearly prohibited and is cause for dismissal from the activity.

3. With interest in the health and well being of our young people, smoking is not permitted at any time.

Your cooperation in adhering to these guidelines is greatly appreciated.

THANK YOU!

Return Form to:  St. Margaret Catholic Church, Office of Youth Ministry, 141 Hickory Avenue, Bel Air, MD 21014.  YOU MUST HAVE A SIGNED PERMISSION
FORM SUBMITTED TO BE A PART OF THE GROUP/ EVENT / TRIP.