World Youth Day Registration Form
Participant Name ____________________________________________________
Parent/Guardian Name ___________________________________________________
Address _______________________________________________________________
Home Phone _______________________ Cell Phone _________________________
Emergency Phone (if above numbers cannot be reached) _______________________
Allergies, Handicaps or other special conditions that apply to participant:
______________________________________________________________________________________
Please fill out all above information
I, the undersigned parent/legal guardian of __________________________ request that my child be
(name of participant)
allowed to participate in World Youth Days to be held at Our Lady of the Snows Shrine – Belleville, IL for
____ jr. high on Saturday, Sept. 25 or for ____high school on Sunday, Sept. 26 , 2010.
I do hereby agree to hold harmless and indemnify the Diocese of Springfield, St. Francis of Assisi parish, and any and all of its agents, employees, chaperons, drivers, coaches or other adults acting as official agents of the above-named parish and diocese from any prosecution resulting from the injury/death of my child as a result of participation in this activity.
Further, in the event of injury to my child, and I cannot be reached, I hereby give permission for necessary medical treatment to be performed by a physician should the need arise.
I also indicate by my signature that I have been informed of the details of this event and that I hereby request that my child be allowed to participate in the stated event. I also authorize my child’s photo to be taken and used for ministry purposes including the parish website.
Additional details:
We will be leaving the grade school parking lot at 8:30 am and returning approx. 11:00pm. Students should pack a sack lunch to eat on the way or when we get there.. Evening meal is included in the day’s events. Cost is $20. Please return this permission slip and check to St. Francis Church,, P.O.Box 730, Teutopolis, IL 62467 or drop in the collection basket BY SEPT. 10th . Checks may be made payable to St. Francis Church.
__________________________________________ _____________________________
(signature of parent/guardian) (date)
****_______ I would love to drive for this event and for my child.
_______ # my vehicle holds besides the driver
If you sign up to chaperon, please consider yourself “ON” for it & please be at the parking lot at 8: 15 am.
