Life is Very Good Evening of Prayer Permission Slip Evening of Prayer (Traveling with the Youth Group Form) Thursday, January 23, 2020, 5:30pm to 10:45pm The cost is $21. You will be redirected to a payment page upon form submission.Youth InformationName* First Middle Last NicknameBirthdate (mm/dd/yy)*Youth's Email* Grade*School*Youth's Cell Phone*T-Shirt Size*SMLXLXXLEmergency Contact and Medical InformationEmergency Contact Adult's Name* First Last Relationship to Youth*Home Phone*Cell PhoneStudent Health InformationFamily Physician*Physician's Phone*Known allergies to any medicineAny other medical problems that should be notedInsurance InformationInsurance Carrier*Policy Number*Phone*Parent/Guardian InformationParent/Guardian's Name (for event contact)* First Last Valid Email (for event information)* Home Phone*Cell PhoneParent/Guardian Information 2Parent/Guardian's Name 2 (for event contact) First Last Valid Email 2 (for event information) Home Phone 2Cell Phone 2By signing below: I, the parent/legal guardian of the youth I have designated above, give permission for my child to attend the Catholic Diocese of Arlington Evening of Prayer on January 23, 2020 located at EagleBank Arena on the Campus of George Mason University 4500 Patriot Circle. Fairfax, VA 22030. Transportation will be via motorcoach departing from St. Theresa Parish 21371 St. Theresa Lane, Ashburn, VA 20147 @ 5:30 PM and returning at approx 10:45PM to St. Theresa Parish. I understand and acknowledge that participation in the activities involves inherent risks of injury to my child including risks associated with transportation by motor vehicle. I agree to indemnify the Parish, Youth Ministers, Volunteers, and the Diocese of Arlington for any costs or expenses arising out of my child’s participation in the activities including the cost of any medical care given my child or any expenses or fees incurred in any lawsuit arising as a result of any damage or injuries caused by my child in the course of his or her participation in the activity. I further give my consent that in my absence the above-named minor may be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. Also, I authorize the Diocese of Arlington and St Theresa Youth Ministry to use my child’s picture or video recording for educational and/or marketing purposes. I understand that in the event my child becomes ill with a communicable illness during the trip, I have to make immediate arrangements to retrieve my child from the trip location.Parent/Guardian's Signature*Date* Date Format: MM slash DD slash YYYY RemarksNameThis field is for validation purposes and should be left unchanged.