St. Stephen Catholic Church
1300 NE “J” Street
Bentonville, AR  72712
(479) 273-1240

Transportation and Medical Care Permission Form / Waiver of Liability

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Name of Person Participating in Activity                         Age                                         Date of Birth

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Allergies or Any Serious Medical Condition We Should be Aware of

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Any Routine Medications / Time to Administer

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Health Insurance Company                                                                               Policy #

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Parent / Guardian                                                                                  Home Phone #

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Address                                                                                                 Work Phone #

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Person to Contact in Case of Emergency                                         Phone #

I permit my son/daughter/ward _____________________________to ride the bus, van or car operated by persons who may or may not be affiliated with the IMPACT/DAWG Pound/CTGIF youth program of St. Stephen Catholic Church for any activities between September 1, 2008 and August 31, 2009.  I understand the risk of injury to person(s) and property(s) inherent with vehicular travel.  I will permit minor first aid / emergency care for my son/daughter/ward if deemed necessary by the adult in charge.  I will not hold the Diocese of Little Rock, St. Stephen Catholic Church, and its representatives and agents liable for any injury which may occur because of negligence during any youth activity.

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Parent/Guardian                                                                    Date

Behavior: All participants in any program by the Early Teen/Confirmation/CTGIF program of St. Stephen’s are expected to show respect for all adults, themselves and their peers, and agree that they will at no time engage in behavior that would cause themselves, their peers, and their church any disrespect.  Participants agree to not use any type of tobacco products, alcohol, or inappropriate language.  If any participant is found with any of these items or using disrespectful language, their parent will be notified immediately, and their privilege for the activity will be revoked.

Activities: throughout the year, several activities will be held outside of class.

v        Information and sign-up sheets will be posted on the Early Teen/Confirmation/CTGIF bulletin board at least two weeks prior to the sign-up deadline.  Activities will be discussed during class time.  It is the responsibility of the youth to pick up this information and sign-up by the deadline.

v        Youth are expected to participate in all activities that they sign-up for.  In the event that unforeseen circumstances make this impossible, youth should call either the Church or the activity coordinator to make them aware of the change.

v        Youth may invite friends to participate in most activities.  Friends must bring a signed permission slip to each activity, and are expected to follow the behavior code.

v        Adults are needed to chaperone all activities to ensure that the event is safe and enjoyable for everyone involved.  Adult chaperones are not required to pay the activity fee.  Al least two adults (excluding teaching staff) are needed to chaperone each event.  If there are not enough adults to chaperone an event, the event will be cancelled.

Fundraisers: We hold several fundraisers throughout the year that help to offset the cost of our activities.  Youth are expected to participate in all fundraisers.  Youth who do not actively participate in fundraising activities may be asked to pay the full cost of future activities.

I have read and understand the guidelines and expectations listed above.

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Youth Signature                                                                                 Date

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Parent/Guardian Signature                                                              Date