Youth Pilgrimage Permission Slip

Participant Information

Name of Youth Participant:

Date of Birth:

Address:

Parent/Guardian Name:

Contact Number:

Pilgrimage Details

Destination:

Date(s) of Pilgrimage:

Chaperone/Leader Name:

Chaperone/Leader Contact:

Medical Information

Allergies or Medical Conditions: Medications (if any): Emergency Contact Name: Emergency Contact Number: Insurance Provider & Policy Number:

Parental Permission

I hereby grant permission for my child named above to attend and participate in the specified Youth Pilgrimage, and authorize the adult leaders in charge to obtain any emergency medical attention as necessary. I release the organizing institution and its representatives from liability for any injury or illness incurred during this event.

Parent/Guardian Signature:

Date: