Saint Raphael Korean Catholic Center

12366 Rosecrans Avenue, Norwalk, CA 90650 Tel: (562) 623-0700 Fax: (562) 623-0024

Event: Location:

Golf N Stuff
Golf N Stuff
10555 E Firestone Blvd Norwalk, CA 90650

Date(s): Cost: Gather Time: Return Time:

Fri., Oct. 19th, 2012 10 7:00 PM 9:30 PM

Gather Place: Pick-up Place: Transportation:

10555 E Firestone Blvd Norwalk, CA 90650

Parents are responsible for arranging transportation to/from this event.

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Event: Golf N Stuff High school Outing Date(s): Fri., Oct. 19th, 2012

I request that my son/daughter be permitted to participate in the activity sponsored by St. Raphael Korean Catholic Center (under direction of St. Linus Catholic Church) for the dates and times listed above. I am not aware of any medical condition of my child that renders it inappropriate for him/her to participate in any such activity. I agree to direct my child to cooperate and conform to directions and instructions of church or archdiocesan personnel responsible for youth activities. I also understand that any child determined to be in violation of the rules of St. Raphael Korean Catholic Center may be sent home at my expense. In the event of any illness or injury as a result of his/her participation in the above named youth activities, including transportation to and from these activities, whether or not caused by the negligence (active or passive) of the parish or archdiocesan youth activities program, or any of its agents or employees, recourse for the payment of any resulting hospital, medical, proprietal or related costs and expenses will first be had against any accident, hospital or medical insurance or any available benefit plan of mine or of my spouse. I release and discharge St. Raphael Korean Catholic Center and its staff from any and all claims for property damage, personal injury, accident, illness, or death that my child may suffer as a result of participating in the activity as described above, whether or not such injuries or damage are caused by the negligence (active or passive) of the church or its staff. I hereby give permission to the physician selected by the youth activities supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician.
Name of STUDENT Name of Parent/Guardian Home Address (Street, City, Zip) Home Telephone Cell Phone Grade Todays Date

Signature of Parent/Guardian

Please list any food or medication allergies that your child has

In the event of an emergency and if unable to contact above, please contact: Name Relationship Phone

St. Raphael Youth Group Activity Permission Slip