Church of St William 


Archdiocesan Youth Day


Please return this form and $15 to the Parish Office

 Student/Participant Name:_______________________________________________

Home Phone: ___________________________ Home Address: ____________________________________________

Date of Birth: ___/___/___ Sex: M / F   Grade in School: ____   Email: ______________________________________

Parent/Guardian:______________________________ Parent/Guardian:______________________________________

Work/Cell Phone :______________________________   Work/Cell Phone :___________________________________

Archdiocesan Youth Day – Oct. 29,2016   Student Cost –  $15     Destination – Roy Wilkins Auditorium – 175 W Kellogg Blvd – St Paul, MN        Individual(s)/Teacher(s) in Charge     Cindy Mauch-Morff     Estimated Time of Departure:  Noon    Return:  9:45 p.m.    Mode of Transportation To & From Event – cars/vans

I would be willing to help drive/chaperone:  Name _______________________________  How many in vehicle: ____

I, _________________________________, grant permission for _ __________________                         Parent or Guardian Name                                                                               Child Name

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 Church of St William, all Churches participating, and the Archdiocese of St. Paul & Minneapolis from any claims or law suits brought against the Church of St William, all Churches participating, and the Archdiocese of St. Paul & 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 Church of St William, all Churches participating, and the Archdiocese in defense of such a claim/suit. Should photos or video be taken, I give my permission for the use of my child’s image and /or likeness in any promotional or other marketing activities relating to the youth ministry programs of the Church of St William and all Churches participating.

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/Relation                                                                                                  Emergency Phone Number

Use of Image:  I grant permission to the Church of St William to use and publish for advertising, commercial or publicity purposes, the name and likeness of my child, or for any other lawful purpose whatsoever, including photographic portraits, picture, reproductions, made through any medium, including electronic media and the undersigned parent/guardian does hereby release the Church of St William and all churches participating with such use.  This authorization and consent permits such use to associate my child’s name with the likeness for such purposes provided such use and is consistent with the acceptable use policy for electronic communications and other policies.

Electronic Communication: I authorize staff or other leaders of the Church of St William and parish leaders to communicate with my child electronically, including via social media in accordance with the Acceptable Use Policy for Electronic Communication.


Medication my child is taking at present: _________________________________________________

Family Health Plan carrier number: _____________________________________________________

Family Doctor: ______________________________ Phone Number: _________________________

As Parent or Guardian, I agree to all of the above stated considerations and conditions.

Signature: ____________________________________________________ Date: _____________________     


 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. (Of the following statements pertaining to medical matters, sign only those that are applicable.)

Medical Treatment: In the event it comes to the attention of the Church of St William or any of the other Churches participating, its officers, directors and agents, and the Archdiocese of Saint Paul & Minneapolis, chaperons, or representatives associated with the activity that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself).

Signature: ____________________________________________________ Date: _____________________

Medications: My child is taking medication at present. My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage, are indicated on attached sheet.

Signature: ____________________________________________________ Date: _____________________

I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate.

Signature: ____________________________________________________ Date: _____________________

Specific Medical Information: The Church of St William and all Churches participating, will take reasonable care to see that the following information will be held in confidence.

Allergic reactions (medications, foods, plants, insects, etc.): _________________________________

Immunizations-Date of last tetanus/diphtheria immunization:_______________________________

Does child have a medically prescribed diet? _____________________________________________

Any physical limitations? ____________________________________________________________

 Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? If so, date and disease or condition:__________________________________________________________________________

Any special medical conditions?________________________________________________________________________



The following are a few rules that all participants are expected to follow while participating and representing the Church of St William in this event sponsored by the Archdiocese of St Paul & Mpls. & Church of St William on the above dates.  Please read and sign.


I, _______________________________________________________, WILL:

                                  Printed Name of Teen

  • Treat all other persons with respect and not cause any intentional harm (physically, emotionally, or spiritually) to any person in any way.
  • Respect the property of others, including all program facilities and property.
  • Follow all appropriate instructions of all personnel aiding in this event, including, but not limited to, chaperones, support staff, transportation personnel and administration.
  • Be on time for all check-ins and departure time.
  • Not have in my possession any tobacco, alcohol or any controlled illegal substance

I agree that if any of these terms are violated, the Church of St William can send the participant home at the participant/guardian’s expense.

__________________________________________________        __________________________

   Participant Signature                                                                                            Date

__________________________________________________        __________________________

 Parent/Guardian Signature                                                                                    Date