For ALL 6th, 7th and 8th Graders Meet at St. Teresa’s Church Parking lot at 5:45 pm to travel by Bus to The Funplex Return to St. Teresa’s by approx. 10:00 pm *$40 per person includes: Unlimited Go-Karts, Super Twister, Lazer Runner, Bumper Cars, Free Fall & 4DTheater AND 10 Tokens, 2 slices of pizza and a soda Permission Forms due by Friday, April 24th! (return page 2 to Rectory Office ASAP, space is limited!) *bring Money for additional food & arcade games!! For more info please contact: Brian Flanagan at [email protected] or 973-500-3300 ext. 703 PERMISSION FORM FOR SPECIAL ACTIVITIES & FIELD TRIPS BOLD Middle Youth Ministry St. Teresa’s Church, Summit, NJ Friday, May 1, 2015— “Funplex Trip”, Rt. 10, East Hanover, NJ ALL TRANSPORTATION WILL BE BY BUS UNLESS OTHERWISE INDICATED. This portion to be completed by parent or guardian. Student Name__________________________________________Age________________Grade____________________ Student Cell #_____________________________________ School___________________________________________ Parent/Guardian___________________________ Email___________________________________________________ Home Phone #________________________________________ Cell #_________________________________________ Address______________________________________________City/State/Zip__________________________________ Emergency Contact ________________________________ Phone ____________________ Relation ________________ Health Insurance Co. _________________________________________ Policy Number___________________________ Please indicate any special medical problems, dietary needs or allergies: _______________________________________ Family Physician__________________________________________ Phone_____________________________________ Parent/Guardian: Please read carefully and sign below I request that my son/daughter participate in the above-‐described activity and consent to the mode of transportation as indicated. Should emergency medical treatment be necessary and I am unable to be contacted immediately, I authorize the delegated agents of St. Teresa of Avila Church to act on my behalf and approve appropriate treatment. I specifically waive any and all claims of any nature I may have against St. Teresa of Avila Church, the Roman Catholic Archdiocese of Newark, their representatives, employees, agents and assigns (including, but not limited to, staff and adult supervisors) relating to or arising out of the above described activity including, but not limited to, claims that may be derived from any accident or injury sustained by my son/daughter en route to, during, and/or returning from the activity. I further understand that parish representatives are NOT permitted to dispense medication. Signature of Parent/Guardian________________________________________ Date_______________________ PARENT CHAPERONES NEEDED!!! Please check appropriate box below: ____I would love to help out for this event! Email _________________________ Cell #__________________ ____I will NOT be able to help at this event, but would love to help out with future events Remember to write down IMPORTANT INFORMATION! Friday, May 1 at 5:45 pm in Church Parking Lot