Form XXIIIC
Parental Permission and Release of Liability – Teen Participant

( One form must be completed for each person attending)

Event: _______________________________Location/Destination:__________________________
Group Leader: _________________________ Group Name: _______________________________
Method of Transportation: ________________ Type of Accommodation: ______________________
Beginning Date/Time: ____________________ Ending Date/Time:__________________________

Cost per person ____________ includes _______________________________________________
________________________________________________________________________________

Participant’s Name: ______________________________________________________M/F:______
Birth date: _____________Phone: _________________Email address: ______________________
Parish: __________________________________________________________________________
Parents/Guardian Name: ____________________________________________________________

Spouse: _________________________________________________________________________
Home address: ______________________________ City:________________State:____ Zip:_____
Parent’s Home Phone #: ( ) ______________________
Parent’s Work Phone #: ( ) _______________________
Parent’s address if different than participants:
Parent’s Name:____________________________________________________________________
Address: ______________________________City: _____________________ State:____ Zip:_____

Liability Release

I/We as parents/guardian give consent and permission for our child ___________________________ to participate in the activity described above with the youth group of Christ the King Church. In consideration of permission granted Christ the King Church and the Diocese of Camden, New Jersey for our child to participate in this activity, we release any and all claims against Christ the King Church, the youth group of Christ the King Church, the Diocese of Camden, New Jersey and their respective agents, servants, employees, officers, trustees, administrators and volunteers, for damages and/or injuries to us or our child which may arise from participation in this activity and agree to indemnify and hold these entities harmless from and against any clai9m or claims brought by or on behalf of our child or by or on behalf of any other person arising out of or in any way connected with our child’s participation in the activity. My teen and I have read and understand the expectations and guidelines as detailed in Form R-4 for this event and will cooperated with these rules. I understand that failure to comply may result in immediate dismissal of my child, with transportation home at my expense. As outlined in the consequence policy.

Parent(s) Signature(s): ___________________________ _______________________________

Date: ____________________________

Parent(s) Print Name(s): ___________________________ _______________________________