Youth Information

Participant First Name *

Participant Last Name *

Grade *

Birthdate *

Sex *

E-mail address *

Parent/Guardian Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Preferred Contact Phone Number *

Parent/Guardian Consent Form & Liability Waiver

I,

Parent/Guardian Name *

grant permission for my child,

Student's Name *

to participate in the event, sponsored by St. Joseph. This activity will take place under the guidance and direction of parish employees and volunteers from St. Joseph.

Type of event: Middle School Lock-In "O Holy Day"

Location of the event: St. Joseph's Catholic Church, 218 10th Street South, Moorhead

Individuals in charge: Melissa Hund-Cerna

Date of event: Saturday, April 6, 4 p.m. to midnight.

Registration due: Wednesday, April 3

Cost of Event: $10, to be paid at check-in on April 6.

As a parent and/or guardian, I remain legally responsible for any personal actions taken by the above named minor (participant). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Joseph’s and St. Francis de Sales, its officers, directors and agents, chaperones, or representatives associated with the event, arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate St. Joseph’s and St. Francis de Sales, its officers, directors and agents, chaperones, or representatives associated with the event for reasonable attorney’s fee and expenses arising in connection therewith.

Parent Signature *

clear

Date: * +