LEAD: WOODY’S Ice Cream, Tuesday Outings High Schoolers, Join us for ice cream at Woody’s Ice Cream! When: Tuesdays Time: 7pm-8:30pm Location: 10435 North St, Fairfax, VA 22030 Complete the permission form below. Woody’s Permission FormPlease enable JavaScript in your browser to complete this form.123STUDENT INFORMATIONStudent's Name *FirstMiddleLastCurrent Grade *9th10th11th12thAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Student's Cell PhoneStudent's Email *Add second students information? *YesNoStudent Name *FirstMiddleLastCurrent Grade *9th10th11th12thStudent's Email *Add third students information? *YesNoStudent Name *FirstMiddleLastCurrent Grade *9th10th11th12thStudent's Email *NextPARENT/GUARDIAN INFORMATIONParent/Guardian Name *FirstLastParent/Guardian Email *Parent/Guardian Cell Phone *Parent/Guardian Work PhoneRelationship to teen?MotherFatherOtherPlease specify your relationship with the student/teen *RELEASE FORMSSAFETY *As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set forth by the Diocese and the Parish.Signature: *Clear SignaturePrint Full Name *PARENTAL PERMISSION AND LIABILITY RELEASE *As the parent/legal guardian, I give permission is hereby given for my child to go on to Woody’s Ice Cream for St. Leo the Great Youth Group’s Lead Team. Between April 26 and May 24, 2022, Lead Team could meet at Woody’s Ice Cream. I understand and acknowledge that participation in the activities involves inherent risks of injury to my child including risks associated with transportation by motor vehicle. I agree to indemnify St. Leo the Great Parish, Youth Ministers, Volunteers, and the Diocese of Arlington for any costs or expenses arising out of my child’s participation in the activities including the cost of any medical care given my child or any expenses or fees incurred in any lawsuit arising as a result of any damage or injuries caused by my child in the course of his or her participation in the activity.Signature *Clear SignaturePrint Full Name *INFORMED CONSENT TO MEDICAL TREATMENT *I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.Signature *Clear SignaturePrint Full Name *PHOTO, PRESS, AUDIO, AND ELECTRONIC MEDIA RELEASE *I authorize the Catholic Diocese of Arlington, its parishes, its schools and/or the Arlington Catholic Herald to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.Signature *Clear SignaturePrint Full Name *NextMEDICAL INFORMATION(ALL INFORMATION IS KEPT PRIVATE)Student NameMEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug NameDosageDrug NameDosageIn case there are additional drugs, please mention the drug name and its dosage below:ALLERGIESEnvironmental (i.e. pollen, dust)Any MedicationsFoodDoes your child have an EPI-pen?YesNoDo they know how to administer it to themselves?YesNoHISTORYMedical History (be specific)Mental Health Information (be specific)Are you registering a second student?YesNoSecond Student's NameMEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug NameDosage Drug NameDosageIn case there are additional drugs, please mention the drug name and its dosage below:ALLERGIESEnvironmental (i.e. pollen, dust)Any MedicationsFoodDoes your child have an EPI-pen? YesNoDo they know how to administer it to themselves?YesNoHISTORYSecond Student's Medical History (be specific) Second Student's Mental Health Information (be specific)Are you registering a third student?YesNoThird Student's NameMEDICATIONS Please list any prescription or doctor prescribed over the counter medications your child is usingDrug NameDosageDrug NameDosageIn case there are additional drugs, please mention the drug name and its dosage below:ALLERGIESEnvironmental (i.e. pollen, dust)Any MedicationsFood Does your child have an EPI-pen?YesNoDo they know how to administer it to themselves?YesNoHISTORYThird Student's Medical History (be specific)Third Student's Mental Health Information (be specific)Physician and Medical InsurancePrimary Healthcare ProviderPhoneInsurance CompanyPolicy NumberEmergency ContactName *FirstLastRelationshipPhoneSubmit