Permission Slip Youth Bus For Life March for Life 2019 Washington, DC Pilgrimage Permission Slip Thursday, January 17, 2019 Depart the North Country 6:00 a.m. - Northern Youth Bus for Life departs from Massena’s Trinity Catholic School parking lot and will stop at St. Mary’s in Canton (6:30 a.m.) & St. James in Gouverneur (7:00 a.m.) 8:00 a.m. - Western Youth Bus for Life departs from IHC High School in Watertown. I hereby give my permission for:(*) Invalid Input to travel to the March for Life, Thursday, January 17, 2019 until Saturday, January 19. I understand travel to and from the coach bus will be by those whom I deem responsible. My child will board a coach bus Thursday morning and travel to Washington, DC. My child will be supervised by Diocesan-mandated Virtus-trained adult chaperones. Overnight accommodations are at Hampton Inn & Suites in Arlington, Virginia. My child may have the opportunity to swim at the hotel pool. Pick-up will be Saturday evening at the bus pick up point. I am aware my child will miss school Thursday & Friday. My signature is below as well as the signature of my child who agrees to obey the rules set forth for their safety. (Total cost is $150). Are you a Student or Chaperone? StudentChaperone Invalid Input Chaperones must be Virtus Trained: Protecting God's Children. This is a diocesan requirement. Pre-registration for the training and a list of locations and more info at http://www.virtusonline.org/virtus/ My child has medication with him/her for: Invalid Input May your child be given ibuprofen if necessary? YesNo Invalid Input My child has a cell phone. The number is: Invalid Input (No cell? Please borrow one) Child's E-mail address: Invalid Input Shirt Size: SmallMediumLargeX-Large2XL Invalid Input (UNISEX SHORT SLEEVED SHIRTS) Grade: Invalid Input I received a detailed itinerary of the trip YesNo Invalid Input I received a list of things participant should/should not bring: YesNo Invalid Input Medical/emergency information Participant’s home phone #:(*) Invalid Input Participant’s Date of birth:(*) Invalid Input Participant’s Street(*) Invalid Input Participant’s City:(*) Invalid Input Participant’s State:(*) Invalid Input Participant’s Zip:(*) Invalid Input Participant’s Parish: Invalid Input Family physician: Invalid Input Physician Phone # Invalid Input Does participant have any medical or physical condition, medication information, or allergies which could interfere with participant’s safety? YesNo Invalid Input If yes, please describe: Invalid Input In the event of an emergency (injury, illness, unforeseen incident), I wish the following person to be notified in case I cannot be contacted: Name:(*) Invalid Input Relationship:(*) Invalid Input Phone #:(*) Invalid Input Alternate phone #: Invalid Input Informed consent As the parent/guardian of the above named minor, I have read the trip itinerary and I understand that there are risks of physical injury associated with participation in these activities. I request that my child be allowed to participate in these activities. I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named minor. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment. In the event it becomes necessary for the sponsor staff-in-charge to obtain emergency care for my child, neither he/she nor the sponsor assumes financial liability for expenses incurred because of the accident, injury, illness and/or unforeseen circumstances. These activities are an extension of the mission of the sponsor program and participant’s conduct is to be in accordance with the sponsor’s rules and regulations. Which bus are you registering for?(*) ------------------------------------------Northern (departs from Sacred Heart in Massena with pick ups at St. Mary's in Canton and St. James in Gouverneur)Western (Departs IHC high school) Invalid Input Check here if you'd be interested in an Eastern bus (leaving from Schroon Lake). Invalid Input Northern (departs from Sacred Heart in Massena with pick ups at St. Mary's in Canton and St. James in Gouverneur) Western (Departs IHC high school) Eastern Bus - Our Lady of Lourdes Catholic Church Schroon Lake Your Full Name:(*) Invalid Input By typing your full name in the Your Full Name field above you certify that everything in this form is true and that you understand what is being asked of you. Your Email:(*) Invalid Input Today's Date:(*) Invalid Input Parent/Guardian Work/Home/Cell Phone #'s:(*) Invalid Input Pledge:(*) I pledge that my child's conduct will, at all times, reflect credit upon themselves, their parents, and their parish/diocese. Your child understands that the rules of conduct apply while on the trip. Invalid Input Questions? Contact your bus captains or chaplain: Western: John and Colleen Miner 518-525-0774 Northern: Fr. Mark Reilly 518-536-1986 Verification: Please check the box next to “I’m not a robot” to show that you are a real person(*) Invalid Input
