_____________________________ _____________  ___________________
Name of Youth                                    Date of Birth         Telephone Number

_____________________________  ________________  ________ ______
Address                                                City                           State          Zip

Who to Contact in case of an EMERGENCY:

_____________________________  ________________  _______________
Name                                                   Home Phone              Work Phone

_____________________________  ________________  _______________
Name                                                   Home Phone              Work Phone

I hereby request that my minor Son/Daughter be allowed to attend the _________ ______________________________________.
As parent or guardian of the above named youth, I have hereby release the Archdiocese of Indianapolis, The New Albany Deanery, St. Michael Parish, parish staff, and/or volunteer leaders from any claim, loss, cost, damage, or expense arising out of any accident or other occurrence causing injury to any person or property during this outing or event.  In case of accident or sickness, the adult in charge has my permission to secure medical attention for my child.  Further, should it be necessary for the participation return home due to medical reasons, disciplinary action, or otherwise, I hereby assume all transportation costs.

Parent/Guardian Signature ___________________________  Date: __________

For more information, please call John Jacobi at the Faith Formation Office - 364-6173.

The E-Bulletin is the weekly newsletter of Saint Michael's Church. It features articles on issues important to you as well as on events and issues affecting the community of Bradford, Indiana.