ST. AGNES (JYM)

                 PERMISSION FORM

______________________________________________   _______        M       F

Name                                                                 Age                Sex

___________________________________________________  (____)______________

Address                                    City                           Phone

___________________________________________________   ___________________

Parish                                                                         Grade

Event: Briarcliff Pavilion BINGO     Date: March 27th &/or April 3rd

                                                PERMISSION

I/We, the parents or guardians of the above mentioned child, for myself/

ourselves and for my/our child, give permission for my/our child to participate in the above mentioned event on the above mentioned date.

                                      MEDICAL AUTHORIZATION

In the event of any injury or illness to my/our child during his/her participation in this event, I/we hereby give my/our permission for the necessary medical treatment to my/our child.  I/we agree that in case of injury to my/our child, I/we will not look to St. Agnes Parish or the Roman Catholic Diocese of Greensburg for the payment of any medical costs or injury related costs.

_________________________________________________    (     )____________________

Parent/Guardian Signature                                      Phone Number

_________________________________________________    __________________________

Insurance Company                                                 Policy Number

(      )_________________________________________   _

Parent Cellular Phone Number/Work Phone Number

Name and phone number of person if parent/guardian is not available