St.

Joseph JUNIOR HIGH YOUTH

1154 Seminole Avenue
West St. Paul, MN 55118
Ann Osendorf, Director

WHO: ALL 7th & 8th Graders!

WHAT: SNOWTUBING at EKO BAKKEN in Scandia
WHEN: SUNDAY, JANUARY 16, 2011
TIME: 3-8pm
COST: $20 includes tubing fee and bus ride.
PERSON IN CHARGE: Ann Osendorf, Jr. High Youth Director
RSVP Call 651-789-8357 or email: ann.osendorf@churchofstjoseph.org
RSVP BY
AY N O O N – P H ON E
FRID Bring extra $ for: Hot Chocolate and
OR EMAIL
and $ with other snacks in the Warming House!
Bring form y 1/16
you Sunda WE NEED PARENT CHAPERONES!
Please check box below if you can help
THANKS IN ADVANCE!

The Church of St. Joseph Parent/Guardian Consent Form & Indemnity Agreement
EVENT: SNOWTUBING at EKO BAKKEN DATE: SUNDAY, JANUARY 16 TIME: 3:00-8:00pm

Participant’s Name____________________________________ Age_____ Grade in School_______

( )Male ( )Female School Attending_____________________________________
E-mail Address_______________________________________
Parent/Guardian Name________________________________________________
Address_______________________________ City/State/Zip__________________
Phone_____________________ (H) Cell_____________________

I, EMERGENCY MEDICAL RELEASE

Parent/Guardian Name In the event of an emergency, I give my permission to transport
my child to a hospital for emergency medical
Grant permission for treatment. I wish to be advised prior to any further treatment by
Participant Name a doctor or hospital. In the event of an emergency, if you are
to participate in the above named activity and I warrant that my child is in good unable to reach me at the above numbers, contact:

health. In consideration of my teen’s participation, I agree to indemnify the Name:

Phone:(H) ___
Church of St. Joseph Parish/School and the Archdiocese of St. Paul/ (C)
Minneapolis from any claims or law suits brought against the parish/school/ ALLERGIES:
Archdiocese of St. Paul/Minneapolis by myself, my child, or others, that arises Medications:
out of any behavior by my teen at the event/activity described above. I also Health Plan:
agree to pay reasonable attorney’s fees or expenses incurred by the parish/ Hospital:
school/Archdiocese in defense of such a claim/law suit. Doctor:
Additional Information: Use back of form.

□ I will allow photos to be taken of my child to be used for SJY2 promotional use. My child’s name will not be used. □ I WILL CHAPERONE (Siblings are welcome)

As Parent/Guardian, I agree to all of the above stated considerations and conditions. FOR OFFICE USE ONLY
Paid
Signed____________________________________________ Date______________. Date
Ck#_______________