Saint Ann's Youth Ministry
124 Cochituate Road / Wayland, MA / 01778

Parental Permission Form

Event: _______________________________________

Name of Participant___________________________ Male_____ Female________ Address___________________________________________________________ Town______________________________________State________Zip_________
Date of Birth_________________________ Email__________________________

Insurance Information:

Family Health Insurance Co._________________________ Policy #________________
Family Physician__________________________________ Phone # ________________
Medication(s)___________________________________ Allergies_________________
Any other information we may need to know:___________________________________

Parental Release:

In signing this form, I hereby certify that the above information is correct and give permission for my child to be transported to and from this activity. I give permission for the release of medical records to an attending physician in case of injury or illness. In the case of medical emergency, I understand that every effort will be made to contact the parent(s) or guardian of my child. In the event I cannot be reached, I hereby give permission to the physician attending my child to hospitalize, secure proper and necessary treatment for my son/daughter, as named herein. I hereby agree that no liability is assumed by the Archdiocese of Boston or Saint Ann's Parish for the claims which may arise out of this activity.

Signature of Parent or Guardian_______________________________
Date_____________ Home Phone ______________Work Phone _____________
In emergency call_____________________________ Phone________________