Altar Server Trip to Alamo Movie Theatre - 2023

Name

This field is for validation purposes and should be left unchanged.

Youth Information

Name*

First Last

Nickname

Birthdate (mm/dd/yy)*

Grade*

Emergency Contact and Medical Information

Emergency Contact Adult's Name*

First Last

Relationship to Youth*

Home Phone*

Cell Phone

Student Health Information

Family Physician*

Physician's Phone*

Known allergies to any food, beverages, and/or medicines - N/A if NONE*

Any other medical problems that should be noted

Insurance Information

Insurance Carrier*

Policy Number*

Phone*

Parent/Guardian Information

Parent/Guardian's Name (for event contact)*

First Last

Valid Email (for event information)*

Home Phone*

Cell Phone*

Parent/Guardian Information 2

Parent/Guardian's Name 2 (for event contact)

First Last

Valid Email 2 (for event information)

Home Phone 2

Cell Phone 2

I, the parent/legal guardian of the youth I have designated above, give permission for my child to attend a movie trip to the Alamo movie theater in One Loudoun on Friday, August 11th, from 12:00pm to 2:30pm. I do hereby agree to release, indemnify and hold harmless chaperones, St. Theresa Parish, Youth Ministers, Volunteers, and the Catholic 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 activities. 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. Photo/Video: Also, I authorize St. Theresa’s Youth Ministry and the Catholic Diocese of Arlington to use my child's picture or video recording for educational purposes and/or marketing purposes. Parents/guardians who do not wish their child to be photographed or filmed should notify the Religious Education Office in writing. I freely execute this Acknowledgement with full knowledge of its content. I understand that in the event my child becomes ill with a communicable illness during the event, I have to make immediate arrangements to retrieve my child from the trip location.

Parent/Guardian's Signature*

Date*

Remarks

Altar Server Trip to Alamo Movie Theatre – 2023