Birth Date: ____________________  Sex: ____________________________

Parent/Guardian's Name __________________________________________

Home Address:_________________________________  Zip: ____________
Home Phone: (     )____________________ Business Phone:(    )___________

I ',^{__________________} , grant permission for my son/daughter,______________________
      ^{Parent or Guardian's Name                                                                                      Child's Name}
to participate in this parish youth ministry event, that requires transportation to a location
away from the parish site. This activity will take place under the guidance and direction
of parish employees and/or volunteers from _Our Lady of the Hills Roman Catholic Church
                                                                              

A brief description of the activity/event follows:

Date(s) of Event: _________________________________________
Type of Event: ___________________________________________
Emergency Telephone Number: ______________________________
Destination: _____________________________________________
Individual In Charge: ______________________________________
Estimated Time of Departure and Return: _______________________
Mode of Transportation to and from Event: _____________________

As parent/legal guardian, I remain legally responsible for any personal actions taken by my
son/daughter named above.

(I_________________________ agree to keep the basic rules of each event and the
consequences of having/using:  alcohol, controlled substances, inappropriate behavior,
etc... My parents will be called and asked to pick me up if I do not keep this covenant. )

I agree on behalf of myself, my son/daughter named herein, our heirs, successors, and assigns to
hold harmless and defend  ___Our Lady of the Hills___________________________________________________________
its officers, directors, agents, and the Diocese of Charleston from any liability for illness, injury or
death arising from or in connection with my son's/daughter's attending the above named event,
and I agree to compensate the parish, its officers, directors and agents, and the Diocese of
Charleston, or representatives associated with the event for reasonable attorney's fees and
expenses arising in connection therewith.

Signature_________________________________________  Date    _______________