Parent Consent form NW Mobile Pack

- Teens

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- FIELD TRIP
  PARENTAL CONSENT FORM & INDEMNITY AGREEMENT
  For Day Trips
- Student/Participant Name REQUIRED Please fill out this field. Please enter valid data.
- Birthdate REQUIRED Please fill out this field. Please enter a date.
- Gender Female Male
- Parents/Guardian Name: REQUIRED Please fill out this field. Please enter valid data.
- Home Address: 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.
- Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Business Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Parish / School: St. Vincent de Paul
  
  Date of Event/Field Trip: February 24, 2019
  
  Type of Field Trip: Service Project
  
  Destination:
  Northwest Metro Mobile Pack at the Egan Company Warehouse,
  11611 Business Park Blvd. Champlin, MN 55316
  
  Individual(s)/Teacher(s) in Charge: Nichole Chang and Catechists
  
  Time of Drop off: 6:00 pm
  Pick up: 8:00 pm
  
  Mode of Transportation To & From Event: Parents provide Transportation
  
  Student Cost (if applicable): NONE
- I grant permission (your name) REQUIRED Please fill out this field. Please enter valid data.
- For (child's name) REQUIRED Please fill out this field. Please enter valid data.
- 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 parish/school and the Archdiocese of Saint Paul and Minneapolis from any claims or law suits brought against the parish/school /Archdiocese of Saint Paul and Minneapolis 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 parish/school and the Archdiocese in defense of such a claim/suit.
- 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:
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact's Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- MEDICAL INFORMATION:
- Medications 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 Please enter valid data.
- Doctor's Phone Number Please enter a phone number.
- As parent or guardian, I agree to all of the above stated considerations and conditions.
  I Agree Please select this field.
- Your Name REQUIRED Please fill out this field. Please enter valid data.
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