NCYC Permission Form:

--Please Print off this copy and turn it in at the Youth Ministry Office (6401 Gages Lake Road, Gurnee, Il 60031) by August 15th 2007--

National Catholic Youth Conference/2007
YMO Youth Permission & Parental/Guardian Authorization
Archdiocese of Chicago Youth Ministry Office
Nov. 8 – 10, 2007

Columbus, OH

I hereby give permission for my son/daughter______________________________(name)
to participate in the National Catholic Youth Conference to take place at Greater Columbus Convention Center in Columbus, OH from November 8 – 10th, 2007, and all travel included to attend this conference.

I HEREBY RELEASE AND INDEMNIFY THE CATHOLIC BISHOP OF CHICAGO, A CORPORATION SOLE, THE YOUTH MINISTRY OFFICE, it's staff and volunteers;
_________________________________(Parish/School name)
it’s staff and volunteers from any and all liability arising from claims of any kind or nature whatsoever from my teen's participation in this event.
I UNDERSTAND that if my son/daughter violates any laws regarding possession of alcohol or drugs, or rules governing the event, arrangements will be made to immediately send my teen
home at the cost of the parents/guardian.
IN THE EVENT THAT THE UNDERSIGNED CANNOT BE REACHED AND IN THE JUDGMENT OF THE RESPONSIBLE ADULT AT THIS EVENT or other staff member, there is a necessity for immediate examination and/or treatment of my teen, I HEREBY AUTHORIZE ANY OF THE AFORESAID PERSONNEL TO OBTAIN FOR MY TEEN, SUCH MEDICAL SERVICES AS ARE DEEMED NECESSARY.

***I GRANT PERMISSION for the adult chaperons for this event to administer non-prescription drugs as needed for my teen i.e., aspirin, ibuprofen, antacids, etc.) YES_____ NO_____

***I AUTHORIZE the Youth Ministry Office of the Archdiocese of Chicago to use photographs/videos of my teen for productions, publications, etc. _____Yes _____NO

PARENT/GUARDIAN SIGNATURE:________________________________________
TELEPHONE #(H)_________________(Cell #)_________________DATE:________
EMERGENCY _________________________________PHONE:__________________
CONTACT'S RELATIONSHIP TO CHILD:____________________________________

****PLEASE LIST any ALLERGIES, MEDICATIONS, MEDICAL PROBLEMS,

PHYSICAL ACTIVITIES/LIMITATIONS that your teen CANNOT take part in
AND/OR any other important information.
_________________________________________________________
_________________________________________________________
_________________________________________________________

CURRENT MEDICATION:______________________________________________
_____________________________________________________________
_____________________________________________________________

PHYSICIAN INFORMATION:
Name of Physician__________________________Phone:________________
Address_____________________City__________State:_____Zip:______


INSURANCE INFORMATION:
Policy in the Name of:_____________________________________________
Insurance Company:______________________________________________
Policy number:__________________________________________________
Identification and/or Social Security Number:______________________________