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Dec. 2nd Lifeline Form

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  Field Trip Parental Consent Form & INDEMNITY AGREEMENT
  
  Parent/Guardian Info.
  
  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 Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Student/participant info.
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Gender and D.O.B. REQUIRED Please fill out this field. Please enter valid data.
  
  Parish/School: Holy Cross AFC
  Date of Event: Dec. 2nd, 2023 Type of Field Trip: NET Lifeline
  Destination: NET Center - West St. Paul, MN
  Individual(s) in charge: Gabrielle Osborne
  Estimated time of Departure: 3:30pm (arrive at 3:15pm) Estimated Return: 11:30pm
  Mode of Transportation to & from Event: Bus
  Student Cost: $10 (please give to Gabrielle before loading the bus)
  **pack dinner to eat on the way up**
  **Drop-off & pick-up in Cathedral parking lot**
  
  I grant permission for my child(ren) to participate in the above named activity and I warrant that my child is in good health. In consideration of my child's participation, I agree to indemnify the Holy Cross AFC / Diocese of New Ulm by myself, my child or others, that arises out of any behavior by my child at the event/activity described above. I also agree to pay reasonable attorney's fees or expenses incurred by the Holy Cross AFC and the Diocese of New Ulm in defense of such a claim/suit.
  
  I Agree Please select this field.
  
  EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to transport my child 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:
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  OPTIONAL MEDICAL INFORMATION:
  
  Medication my child is taking at present: Please enter valid data.
  
  Allergies: Please enter valid data.
  
  Other medical conditions: Please enter valid data.
  
  Family health plan carrier number: Please enter valid data.
  
  Family Doctor & their phone number: Please enter valid data.
  
  Family Doctor & their phone number: Please enter valid data.
  
  As a parent/guardian, I agree to all the above stated considerations and conditions.
  
  Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
  
  Submit
  
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