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ADULT Annual Event Permission Slip

to be completed each year by adult chaperones

This form is to be completed each year by all adult chaperones.
It is a 'blanket permission slip' for adults only. Youth will continue to need a separate permission slip for each Youth Activity we hold off-site.

Adult Chaperone Information

Name of Adult Chaperone

First Name*

Last Name*

E-mail of Adult Chaperone

Required*

Address of Adult Chaperone

Street 1*

Street 2

City*

State*

Zip*

Phone # of Adult Chaperone

Required* --

Please list the phone # that is the best way to reach you. For most people, the best number is a cell phone.

Parish of Adult Chaperone

Required*

Adult Consent & Release

Digital Signature	By typing my full name & today's date, I give this consent as a blanket permission slip for myself, for all Youth events this Ministry Year.*	RELEASE OF LIABILITY FOR THE DIOCESE OF FORT WAYNE-SOUTH BEND I hereby acknowledge recognition that participation in the event may expose myself to risks and hazards. Further, on behalf of myself, I hereby release and agree to hold harmless the above named parish and the Diocese of Fort Wayne-South Bend, Inc. to the fullest extent permitted by law from any and all claims, judgements and liability of every kind for any injury and damage of any kind, whether personal or property, that I or any one of us may suffer or incur due to my participation in the event, regardless of whether the injury or damage is attributable to the fault of parties other than the Diocese or attributable to the fault, including negligence, of the Diocese, its staff, event chaperones, group leaders and/or event organizers.