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Bensonhurst Cluster- Office of Youth Ministry

Parental Consent/ Medical Release Form


Event Information


Event:_______________________________________________________ Cost: ______


Date: ____________________ Time: _________________________


Youth Information

Name of Child:  ____________________________________________________

Date of Birth: ___ /___ /___ 

Our Parish Affiliation:___________________________________________________

School Affiliation: ___________________________________________

Home Address: ____________________________________________________________________________ Phone: ________________________

Email Address: _________________________________

Parent/ Guardian Information

Parent(s)/ Guardian(s) Name: _______________________________________

Phone # __________________

Address: __________________________________________________________________________________      (If different from above)

Parent(s)/ Guardian(s) Email Address(es): ___________________________________________________________

Additional Emergency Contact

Name: __________________________ Phone # __________________ Relationship: _________________


 General Consent and Release: I hereby request and give my permission for my child to participate in the above event.  I understand and assume the risks inherent with this event from other parties, but I also understand that all reasonable care and supervision will be exercised to provide for the general well-being of my child.  I  realize my child will only be under supervision while in the building and I take responsibility for their whereabouts and safety before and after the time indicated above and once they leave the program. I individually and on behalf of my child named above, do hereby release, covenant not to sue, and save harmless:  The Diocese of Brooklyn; the Cluster Office of Bensonhurst; the individual parishes and schools (St. Athanasius, St. Finbar's, St. Simon and Jude, St. Regina Pacis/St. Rosalie, St. Francis Cabrini, Our Lady of Guadalupe, St. Dominic, St. Mary, Mother of Jesus),  host site and all employees, agents and volunteers for the event, from any and all claims for any and all harm arising to my child as a result of their participation in this event. 

Medical:  In the unlikely event of injury or illness during this event and I agree to pay any expenses incurred for treatment and will either personally or give permission to my emergency contact to be available to bring my youth for treatment or to the hospital.  

Parent/Guardian _______________________________________  Date: _____________

Signature ________________________________

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