<p> PARENTAL PERMISSION / LIABILITY RELEASE / CONSENT TO TREAT (Please print clearly)</p><p>Student Name: ______Gender: ______T Shirt Size______</p><p>Age: ____ Grade: ______Home Phone: ______Cell Phone: ______</p><p>Home Address: ______City ______</p><p>Parent/Guardian Name(s): ______</p><p>Email Address(es): ______</p><p>Emergency Contact Name & Phone Number: ______</p><p>Physician: ______</p><p>Insurance Co.: ______Health Insurance Policy #: ______</p><p>Medications/Allergies/Other Conditions of Note: ______I, the parent/guardian of the above-named minor child, in consideration for my child being permitted to attend Camp Veritas at BroomTree Retreat Center in Irene, SD, with the St Charles Borromeo Youth Ministry program from Sunday, July 23rd to Thursday, July 27th, hereby give my permission for said child to attend said event and agree to indemnify and hold harmless, to the furthest extent permitted by law, the Archdiocese of St. Paul and Minneapolis, St Charles Borromeo of the city of St. Anthony, and any and all of its/their employees, supervisors, and/or volunteers from any harm, claim for damages, cause of action, lawsuit or other legal proceeding resulting from the injury or death of my child, (and/or for myself if I attend said event also).</p><p>Further, in the event of injury to said child and I cannot be reached, I hereby grant authorized medical professionals the right to administer necessary emergency treatment to my child.</p><p>I affirm that I have read and understood and agree with the above statements, and show my affirmation and consent by my signature affixed below.</p><p>______Signature of Parent or Guardian Date</p><p>*My child may have their picture published in various St. Charles publications. Please initial______</p><p>* My child has read the “Camp Veritas Retreat Overview” handout and understands his/her expectations. Please initial ______</p><p>* Please turn in the signed liability and $200 (or $50 deposit) to the St. Charles Parish Office or Rachel Houglum by Thursday, July 13th. Checks should be made payable to “St Charles Borromeo Church.” You may also pay online on the St. Charles Borromeo Parish website.</p>