STMTYM Trip to
a NJ Devils
Hockey Game
Join STMTYM as we head off to the “The Rock” to take in a NHL
game! The NJ Devils are playing the Nashville Predators!
Bus leaves from St. Theresa’s Parking lot at 5:30pm.
We will return back to St. Theresa’s around 10pm, est,
We only have 25 tickets!
VS.
TUESDAY DECEMBER 20
7:00 PM game
Tickets are $40 Includes bus transportation and ticket to the
game. Return the permission slip and $40 no later than
December 18th. If paying by check please make it payable
to St. Michaels.
Saints Michael & Theresa Youth Ministry Permission/ Release Form
Participant’s Name _____________________________________ Age _______________
Address ___________________________________________ HOME Phone ________________
City _____________________ Date of Birth _____________ Grade ________________
TEENS CELL # __________________________ TEENS Email : _____________________@ ___________
Does your son/ daughter have any medical problems, allergies that we should know about ?
Yes _______ No _______ If yes, please explain.
Is your son/ daughter on any medication? Yes _______ No ________
If yes, please describe the kind of medication, dosage, frequency and administration by whom authorized.
******************************************************************************
Parent or / Emergency Contact:
Name ______________________________________
Cell Phone _________________________
Address _________________________________________
Relation _______________________
******************************************************************************
I give permission for my child to participate in the Saints Michael & Theresa Youth Ministry NJ Devils Game Trip on
Tuesday December 20th, 2016 I hereby waive and release any and all rights and claims for damages which I may have
against St Michael OR St. Theresa Parish’s, and all of their agents, servants, and employees, for any injury my child may
incur while taking part in your program. This release also encompasses any injuries which may be sustained while traveling to and from participation in the program. As a parent I understand that it is my responsibility to pick my child at
the predetermined time. I also understand that if my child becomes ill or destructive I will be contacted, and if I cannot
be reached the above “Emergency Contact” will be called to take my child home.
___________________________________________
**Parent/ Guardian Signature
______________________
Date
******************************************************************************
I hereby waive any and all rights and claims for damages which I may have against Sts. Michael and/ or Theresa’s
Parish, and their agents, servants, and employees, for any and all injuries which I may incur while taking part in your
program. This release also encompasses any injuries which may be sustained while traveling to and from participation
in the program. I also understand that if I become destructive or ill my parents and/ or the above “Emergency Contact”
will be called to take me home.
___________________________________________
______________________
**Signature of Youth Participant
Date
THIS FORM AND MONEY MUST BE RETURNED TO THE
YOUTH MINISTRY OFFICE NO LATER THEN SUNDAY December 18th !!