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P E R M I S S I O N F O R M Junior Youth Ministry
Dear Parent or Legal Guardian: Your son/daughter is eligible to participate in a parish wide-sponsored activity. This activity will take place under the guidance and supervision of St. Agnes, St. Elizabeth Ann Seton and Immaculate Conception Parish Adult chaperones. A brief description of the event follows.
NAME OF EVENTS: “BINGO” with the nursing home residents
LOCATION: #1. Juniper Village ( just beyond turnpike entrance) OR #2. Briarcliff Pavilion Nursing Home … 249 Maus Dr. N. Huntingdon, PA 15642
DATE: #1. Monday, October 26, 2009 (Juniper Village) OR #2. Tuesday, October 27, 2009 (Briarcliff Pavilion)
TIME: #1. 7:00 – 8:00 PM OR #2. 7:00 – 8:00 PM
OTHER: ***Bring permission slip for either day ***Bring Dollar Store Prizes…NO CANDY! ***We need adult help…can you stay to help? Call Mary and leave a message 724-864-5393 to let her know which night you can stay to help!
QUESTIONS: Call…Mary Blythe 724-864-5393, Sr. Charlene 724-864-6364, Ginny McConnell 724-863-9550
If you would like your child to participate in this event, please complete, sign and return the following statement of permission. As a parent or legal guardian, you remain fully responsible for any legal responsibility that may result from any personal actions taken by the named child.
I hereby consent to the participation by my child, ________________________________________ in the event described above. I understand that this event will take place away from parish grounds and that my child will be under the supervision of St. Agnes, St. Elizabeth Ann Seton and Immaculate Conception Parish parent chaperones on the stated date. I further consent to the conditions stated above on participation in this event.
In case of an emergency, please contact us at this phone number: _______________________________
I/We are unavailable contact (Name) _____________________________________________
(Phone) _____________________________________________
__________________________________________ Print Parent’s Name
__________________________________________ Parent’s Signature
__________________________________________ Date
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