Please list all allergies.
Please list all medication that your child takes regularly.
I give permission for my child to take part in the Our Lady of Prompt Succor Youth Program activities on and off church grounds. In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do herby release, absolve indemnify, and agree to hold harmless the Diocese of Alexandria and Our Lady of Prompt Succor Church, its agents, employees and officers, the chaperones, leaders, organizers, sponsors, and persons transporting our child to and from these activities. Neither the Diocese of Alexandria and Our Lady of Prompt Succor Church, nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of this activity. I, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance. In the event of an emergency and I cannot be contacted, I hereby authorize that emergency treatment may be administered.