Our Mother of Good Counsel Church

Youth Ministry/Confirmation Preparation Program

PERMISSION SLIP

FIELD TRIP TO MUSEUM OF TOLERANCE

I, __________________________, give my permission for my son/daughter,_____________________

to participate in a field trip to the MUSEUM OF TOLERANCE on Sunday, January 20, 2008. I understand that OMGC will charter a school bus which will depart from the OMGC parking lot at 1:30 p.m and returning by 6 p.m. I understand that the objective of this excursion is educational. I give permission to Theresa Costanzo and her volunteer chaperones to seek medical treatment should it be necessary for my son/daughter and to authorize any and all appropriate tests and treatment deemed necessary by the attending physician in the case of a medical emergency.

___________________________________ __________________________________

Insurance Company Policy Number

My insurance carrier requires approval of treatment by assigned facility: Yes___ No___

If yes, please contact ____________________________ at _______________________

Name of assigned facility Phone Number

In case of emergency, please contact me at ____________________________________

Additional emergency contact is__________________________at__________________

Parent Signature________________________________Date______________________

ENCLOSED IS PAYMENT IN THE AMOUNT OF $10 (PAYABLE TO OMGC).

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PERMISSION SLIP - 2008 YOUTH DAY

I, __________________________, give my permission for my son/daughter,_____________________

to attend the all-day Catholic Youth Day at the Anaheim Convention Center on Thursday, February 28, 2007. I understand that OMGC will charter a school bus which will depart at 7:00 a.m. from the OMGC parking lot and returning at about 5:30 p.m. I understand that the objective of this conference is to experience faith and fellowship with other Catholic youth in the Los Angeles archdiocese.

I give permission to Theresa Costanzo and her volunteer chaperones to seek medical treatment should it be necessary for my son/daughter and to authorize any and all appropriate tests and treatment deemed necessary by the attending physician in the case of a medical emergency.

___________________________________ __________________________________

Insurance Company Policy Number

My insurance carrier requires approval of treatment by assigned facility: Yes___ No___

If yes, please contact ____________________________ at _______________________

Name of assigned facility Phone Number

In case of emergency, please contact me at ____________________________________

Additional emergency contact is__________________________at__________________

Parent Signature________________________________Date______________________

ENCLOSED IS PAYMENT IN THE AMOUNT OF $35 (PAYABLE TO OMGC)