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.

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Cell Phone *

Parent/Guardian Work Phone

Relationship to teen?

SAFETY *

As the participant, I agree to follow all procedures, safety precautions, and rules and regulations set forth by the Diocese and the Parish.

Signature: *

Print 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 *

Print 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 *

Print 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 *

Print Full Name *

MEDICATIONS