Babysitting Permission Form printable pdf download

Babysitting Permission Form

This form is

REQUIRED

for ICC to Babysit your child(ren)

Please hand in prior to or bring along to Babysitting Night! Thank You!

Children(s) Name(s) & Birth Date(s):

Parent/Guardian’s Name

Home Phone:

Cell Phone(s):

Place of Destination(s):

Destination(s) Phone Number (Optional)

Est. Return Time:

Individuals in Charge:

Tracy Duske

I, ____________________________, grant permission for ____________________________

Parent/Guardian Name

Child’s Name

to participate in the above named activity and I warrant that my child is in good health. In

consideration of my child’s participation, I agree to indemnify the Immaculate Conception Church

and the Archdioceses of St. Paul/ Minneapolis from any claims of law suits brought against the

Immaculate Conception Church/Archdiocese of St Paul/Minneapolis by myself, my child or

others, that arises of any behavior by my child at the event/activity described above. I also agree

to pay reasonable attorney’s fees or expenses incurred by the Immaculate Conception Church

and Archdiocese in defense of such a claim/law suit.

EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to

transport my child to a hospital for emergency medical treatment. I wish to be advised prior to

any further treatment by a doctor or hospital. In the event of an emergency, if you are unable to

reach me at the above number, contact

______________ ________________.

(Name)

(Phone)

OPTIONAL MEDICAL INFORMATION:

Medication my child is taking at present: _________________________________

My Child is allergic to: _______________________________________________

Family Health Plan Carrier Number:_____________________________________

Family Doctor:______________________________________________________

As Parent or guardian, I agree to all of the above stated considerations and conditions.

______________________________________________

__________________

Signature

Date

Babysitting Permission Form