Alien Mini Golf and Chill Ice Cream

(St. Augustine Parish, Barberton)

WEDNESDAY, July 10, 2019

This form is due in no later than Monday, July 8.

Join us for a fun night of mini golf and ice cream! For anyone who would like to carpool we will meet at St. Augustine at
5:15 to leave, or if you prefer you may meet us there at Alien Vacation Mini Golf Attraction at Castle Noel, 260 S
Court St, Medina, OH 44256, at 6:00. After a game of mini golf we will head to Chill Artisan Ice Cream (11 Public
Square, Medina, OH 44256) for ice cream. We will leave Chill at 8:00 and return to St. Augustine at 8:30.

Cost is $11 a person. Money will be paid individually to Alien Mini Golf, please DO NOT send in a check with the
permission form.

What to Bring:
Extra money for ice cream.

Please KEEP the top section as your reminder!!

Please return this section and parent signature by Monday, July 8 to Miss Jackie.

I, ________________________________, am the ________________________________ of

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

_______________________________, a participant in Alien Mini Golf and Chill Ice Cream.

(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)

____________________________________________________________________________
___ I am willing to chaperone and bring people in my vehicle. I have ____ seats available.

___ I am not available to chaperone and my son/daughter will need a ride.

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.