Silver Creek Day

(St. Augustine Parish, Barberton)

WEDNESDAY, July 24, 2019

This form is due in no later than Monday, July 22.

Join us for a fun day at Silver Creek! We will meet at Silver Creek Metro Park, 5000 Hametown Rd., Norton, OH
44203. We will have a picnic, hike, Frisbees, etc.

This is a FREE event. Families are welcome to join, please indicate how many people are attending at the bottom of this
form. If you’d like to swim you’ll need to have a pass (a day pass is $5 a person).

What to Bring:
Sunblock and any outdoors type of game you’d like to play. If you would like to swim, bring a swimsuit
and $5 for a pass.

Please KEEP the top section as your reminder!!

Please return this section and parent signature by Monday, July 22 to Miss Jackie.

I, ________________________________, am the ________________________________ of

(Name of Parent/Guardian) (Father, Mother, etc…)

_______________________________, a participant in Silver Creek Day.

(Student’s name)
I hereby request permission for the above named child/children to attend the St. Augustine trip to paintballing and I consent to the child’s
participation in this retreat. I understand that I must provide transportation to and from the Church for my child. I hereby assume all risks in
connection with the youth event and I further release discharge, and/or otherwise indemnity the Diocese of Cleveland, the Bishop of the Roman
Catholic Diocese of Cleveland, St. Augustine, employees and volunteers from all claims, judgments, liability by or on behalf of my child, my self and
my spouse for any injury or damage due to the child’s participation in the youth event including all risks connected therewith whether foreseen or
unforeseen. Furthermore, I acknowledge that it is my responsibility to provide adequate health insurance for my child/children. I understand I have
the opportunity to call Jaclyn Snyder at 330-745-1080 and ask her about the youth event.

Child’s Name _____________________________ M/F? Age ____ School _______________

Address__________________________________ City __________________

Parent’s Cell/Emergency#__________________ Parent’s E-Mail_____________________________

Signature of Parent/Guardian_________________________________________

Allergies _____________________________________________________________________

Please list any health problems you may have and any medications being taken at the present time. (Confidential)

____________________________________________________________________________

Total number of participants from your family ______________

YES/NO I give permission to St. Augustine, her staff, and her volunteers to use photos from this event of
my child(ren) for the website, facebook page, or any other social media as deemed appropriate.