ST.

ANDREW KIM PERMISSION YOUTH GROUP PERMISSION SLIP

EVENT: DATE: FEE:

FRESHMAN-SOPHOMORE MIDNIGHT RUN

Saturday 9/15/2012 (from 2PM to Sunday 1AM) NONE

STUDENT NAME:_______________________________________ DATE OF BIRTH:_____________________ GRADE:________________ EMAIL ADDRESS:______________________________________ NAME OF PARENT OR GUARDIAN:__________________________ HOME PHONE NUMBER:_______________________ CELL NUMBER:_________________________
Please list all information pertaining to allergies, diet, special medication, MEDICAL INFORMATION: health conditions or any other information necessary in an emergency situation. Explain Fully.

IN CASE OF EMERGENCY, if you are unable to reach me at the above numbers, please contact: NAME / RELATIONSHIP: PHONE:

CONSENT AND RELEASE

General: I hereby request and give my permission for my child to participate in the above event. I understand and assume the
risks inherent with this event from other parties, but I also understand that all reasonable care and supervision will be exercised to provide for the general well-being of my child. I individually and on behalf of my child named below, do hereby release, covenant not to sue, and save harmless: The Most Rev. John Myer, Archbishop of the Arch-Diocese of Newark; the parish St. Andrew Kim Korean Catholic Church; the Youth Ministry; and all employees, agents and volunteers for the event, from any and all claims for any and all harm arising to my child as a result of their participation in this event. Medical: I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of an emergency, I hereby give permission to the Archdiocese of Newark, St Andrew Kim and all employees, agents and volunteers for the event, to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. I hereby authorize the medical personnel or a representative of Saint Andrew Kim to administer non-prescription medication (such as Tylenol, aspirin, throat lozenge, PeptoBismol, Neosporin, basic First Aid, etc.) to be given to my child, if deemed advisable.

PARENTS SIGNATURE: _______________________________________________________________ DATE______________