Haunted House Permission Slip

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Immaculate Heart of Mary Church Service Permission Slip/Medical Release You are representing the Archdiocese of Indianapolis and Immaculate Heart of Mary Church during our outing. We expect that you will display a mature and responsible behavior, which for many years has been the trademark of Catholic youth. Expectations are: All participants are expected to arrive on time. All participants are expected to demonstrate courtesy and respect. Dress should reflect the value of modesty. Possession or consumption of any alcoholic beverage and/or possession/use of any illegal drug by an individual is not permitted. Smoking is not permitted. Any prescription drugs need to be given to an adult for storage and distribution. I understand and agree to this behavior code. I also understand and agree that my parents or guardians will be notified at the time of the infraction requiring my dismissal. My parents or guardian will be responsible for my removal from the premises.

Youth Name:

E-Signature:

My Child:

will participate in the haunted house trip to the The Children’s Museum on Friday, October 30. I hereby release and indemnify the Youth Minister, staff, volunteers and the Archdiocese of Indianapolis from any and all liability from claims of any kind or nature whatsoever from my child’s participation in this event. I understand my child will travel back and forth in a parent’s vehicle. I understand that I will be notified at the time of any major infraction by my child, which will result in his/her dismissal from the trip. I grant the permission of First Aid to be given to my child by the people in charge of the event, and those transporting any child to and from the service projects as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult start to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery, if deemed necessary for my child.

Parent Name (s):

Home Phone Number:

Cell Number:

Emergency Number:

I give permission for my child's photo to be on the bulletin board or website at IHM:

Yes

Parent's E-Signature*:

Date:

Yes, I would love to drive and stay at The Children's Museum. Sign me up!

No, I am unable to volunteer at this time

Email:

*Electronic Signature Agreement: By typing your name and dating it, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting typing your name and dating it you consent to be legally bound by this Agreement's terms and conditions. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Immaculate Heart of Mary.