App4

FORM B: EVENT SPECIFIC CONSENT AND RELEASE
Diocese of Wilmington
Parish/Diocesan Institution Trip/Event Consent and Release

My child (please print ful name) _______________________________ has my
permission to attend ___________________________ to be held at
______________________ on ___________________ from ________ to ________.
I understand that the participants wil travel via ________________________ to/from the event.
I hereby give my permission for my child to attend said event and I understand that my child wil be
chaperoned by responsible cleared adults. I understand that CYM, the Diocese of Wilmington and its
staff are committed to providing fun, safe, educational experiences and that CYM events are
conducted in smoke-, alcohol-, and drug-free environments. In light of this, and to help ensure the
safety of al concerned, I understand that if my child is in possession of drugs, alcohol, or tobacco
products, engages in il egal, immoral, or offensive behaviors, or refuses to fol ow the directions given
by CYM staff or volunteers while participating in this activity, I wil be contacted immediately to pick up
my child. As parent/guardian, I understand that promotional pictures (individual and group) wil be
taken during this event. I give permission for my son’s/daughter’s picture to be used for promotional
materials (newsletter, web page, calendars, power point, etc.) in highlighting the event.
By my signing this, I release CYM Staff, The Office for Catholic Youth Ministry, additional chaperons,
and the Diocese of Wilmington from any and al liabilities and waive al claims against them. I also give
my permission for the event coordinator and other qualified cleared adults to obtain proper medical
treatment for my child should it become necessary.
Insurance Carrier/Policy Number
__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Electronic/mobile communication affords the CYM staff or event coordinators the best means of providing reminders and updates to participants. Please provide an email address and/or cel phone number for such communication purposes. Unless provided on Form A (Annual Consent and Release), providing information here limits its use to this particular activity or event. E-mail address _____________________________________ Cel Number _________________________ If necessary, the group leader is permitted to administer the fol owing over the counter medications to my child:  Advil  Other (please specify) __________________________ Signature of Parent/Guardian:
Relationship to Participant:
*If Prescription Medication is indicated, Form C is required.

Source: http://www.stjosephonthebrandywine.org/religious_education/form_b_revised.pdf