Summer Events Permission Slip

- Formation

The maximum number of form submissions has been reached. This form is currently not available.
- Church of Saint John the Evangelist of Little Canada
  380 Little Canada Rd.
  Little Canada, MN 55117
  651-484-2708
- Summer Events Participant Parental Consent Form and Indemnity Agreement
- Parent/Guardian Name REQUIRED Please fill out this field. Please enter valid data.
- Home Address (Number and Street) REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Type of Event: 2020 Summer Faith Formation Program at the Church of Saint John the Evangelist of Little Canada.
  
  Type of Event: Grades 1-5 and 6-8 will also be taking a walk along the trails in Spooner Park on 8/18 and 8/11, respectively.
  
  Duration: 3 days, as scheduled
- Student Participants REQUIRED Please fill out this field.
  
  Student 1
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
  
  Student 2
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
  
  Student 3
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
  
  Student 4
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
  
  Student 5
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
  
  Student 6
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
  
  Student 7
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
  
  Student 8
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
  
  Student 9
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
  
  Student 10
  
  Student Participant Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade Completed (1-12) REQUIRED Please fill out this field.
  
  Date of Birth REQUIRED Please fill out this field. Please enter a date.
  
  Sex REQUIRED Please fill out this field.
- Permission:
  
  I,
- Parent/Guardian Name REQUIRED Please fill out this field. Please enter valid data.
- grant permission for
- Participant Name(s) REQUIRED Please fill out this field. Please enter valid data.
- to participate in the above named activity and I warrant that my child(ren) is in good health. In consideration of my child(ren)’s participation, I agree to indemnify the above named parish-school and the Archdiocese of Saint Paul and Minneapolis from any claims or law suits brought against the above named parish-school, Archdiocese of Saint Paul and Minneapolis by myself, my child(ren) or others, that arises out of any behavior by my child(ren) at the event/activity described above. I also agree to pay reasonable attorney’s fees or expenses incurred by the parish/school and the Archdiocese in defense of such a claim/suit.
  
  I also hereby waive and release the named church and the Archdiocese of St. Paul/Minneapolis from all claims and liability arising from any acts or omissions by the church, Archdiocese or their agents with regard to any injuries or damages incurred by my child during the ordinary course of the event/activity. This release and waiver shall not apply to claims that may arise from intentional acts.
  
  EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to transport my child(ren) to a hospital for medical treatment. I wish to be advised prior to any further treatment by a doctor or hospital. In the event of any emergency, if you are unable to reach me at the above numbers, contact
- 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 Please fill out this field. Please enter a phone number.
- Medical Information:
- Medication my child(ren) (Specify which child) is currently taking: REQUIRED Please fill out this field. Please enter valid data.
- Allergies (specify by child): REQUIRED Please fill out this field. Please enter valid data.
- Other Medical Conditions: REQUIRED Please fill out this field. Please enter valid data.
- Family Health Plan Carrier Number: REQUIRED Please fill out this field. Please enter valid data.
- Family Doctor Please enter valid data.
- Family Doctor Phone Number: Please enter valid data.
- AUTHORIZATION, CONSENT AND RELEASE FOR USE OF VISUAL LIKENESSES AND ORIGINAL WORKS OF MINORS
  
  I authorize and consent that above named school-parish and the Achdiocese of Saint Paul and Minneapolis be permitted to use and publish for general communications, advertising, commerical or publicity purposes, or for any other lawful purpose whatsoever the likeness of My Child and My Child's original work, including video, photographic portraits, pictures, or reproductions, made through any medium, including social or other electronic media, in accordance with the Acceptable Use Policy for Electronic Communications and the Social Media Policy, provided only the first name (not the family name) is identified if any name is used. I hereby release above named school-parish, the Archdiocese of Saint Paul and Minneapolis, and anyone authorized by above named school-parish or Archdiocese of Saint Paul and Minneapolis with such use. This consent regarding My Child's likeness or original work is valid for one year. If I choose to rescind my authorization and consent, I agree that I will inform above named school-parish in writing and that my rescission will not take effect until it is received by above named school-parish. I understand however that it may not be possible to recall any work or photos that have been published prior to receipt of my written rescission. I have read the above Disclosures, Authorizations, and Releases, have had the opportunity to consider their terms, and understand them. I execute this document voluntarily and with knowledge of its significance.
- As Parent or Guardian, I agree to all of the above stated considerations and conditions.
- 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.
Total:

Submit

Proceed to Payment

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Summer Events Permission Slip

Permission:

AUTHORIZATION, CONSENT AND RELEASE FOR USE OF VISUAL LIKENESSES AND ORIGINAL WORKS OF MINORS