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  Chelmsford Catholic Collaborative
  Event Permission Form
  
  Basic Information
  
  Name of Event Participating In REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Event Please enter a date.
  
  Youth Name REQUIRED Please fill out this field. Please enter valid data.
  
  Date of Birth REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian Name(s) REQUIRED Please fill out this field. Please enter valid data.
  
  Home Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Parent/Guardian Mobile Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Emergency Contact Person REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Youth REQUIRED Please fill out this field. Please enter valid data.
  
  Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
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  Medical Information
  
  Does your youth have any medical conditions we should be aware? REQUIRED Please fill out this field. Please enter valid data.
  
  Does your youth have any food or environmental allergies? REQUIRED Please fill out this field. Please enter valid data.
  
  Does your youth have any medical allergies? REQUIRED Please fill out this field. Please enter valid data.
  
  Will your youth be bringing any medication with him/her? REQUIRED Yes No Please fill out this field.
  
  If Yes, please list
  
  Name of Health Insurance Carrier REQUIRED Please fill out this field. Please enter valid data.
  
  Health Insurance Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  Health Insurance Policy Number REQUIRED Please fill out this field. Please enter valid data.
  
  Name of Doctor REQUIRED Please fill out this field. Please enter valid data.
  
  Doctor Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
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  Medical and Liability Release
  
  I hereby give permission for my child to participate in Holy Rood Collaborative Youth Programming.
  
  In case of an emergency, I understand that every effort will be made to contact the undersigned.
  
  In the event the undersigned cannot be contacted I give permission for my son/daughter to be evaluated, diagnosed, treated and/or medicated by licensed medical personnel.
  
  I give permission for the release of any medical records, which I have provided to medical personnel in case of illness. Further, I agree to accept any and all financial responsibility as a result of scheduling such treatment.
  
  I hereby release the Roman Catholic Archdiocese of Boston, a corporation sole, its agents, servants and employees, its priests, in addition to St John the Evangelist Parish & St. Mary Parish & St. Margaret Parish and/or staff and/or volunteers from any and all liabilities in that my son/daughter sustains injury or medical care/treatment is provided.
  
  I understand and agree to the following guidelines for my son/daughter:
  
  Respectful behavior will be demonstrated towards other youth, adult volunteers, collaborative staff, and clergy.
  
  Respectful behavior will be demonstrated towards things and propert(ies).
  
  Instructions given by leaders and chaperones will be followed.
  
  Safety procedures are to be observed.
  
  Appropriate dress is expected at all times.
  
  The character and integrity of a Catholic Christian will be exhibited.
  
  Use of alcohol or illegal drugs is absolutely prohibited.
  
  I understand that the parish will not be held liable if my son/daughter fails to cooperate with these guidelines and that failure to follow these guidelines may result in dismissal from the program. I will be responsible for any costs or other requirements for transportation home.
  
  By checking this box and typing my name below, I am stating that I fully agree and accept the terms of the Medical and Liability Release. REQUIRED I accept Please fill out this field.
  
  Enter First and Last Name REQUIRED Please fill out this field. Please enter valid data.
  
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  PHOTOGRAPH and VIDEO RELEASE
  
  I hereby give permission for my child to be photographed and video'd by staff and volunteer chaperones of the Holy Rood Collaborative. These photographs and videos may be used reasonably by the Holy Rood Collaborative in all publications, including electronic publications, and/or in audio visual presentations, promotional literature, advertising or in similar ways such as in social media channels directly owned by the Holy Rood Collaborative.
  
  By checking this box and typing my name below, I am stating that I fully agree and accept the terms of the Photograph and Video Release. REQUIRED I accept Please fill out this field.
  
  Enter First and Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Submit
  
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