LEBANON CATHOLIC SCHOOL

Dear Parent or Legal Guardian:

Your son/daughter is eligible to participate in a school-sponsored activity requiring

transportation to a location away from the school building. This activity will take

place under he guidance and supervision of employees from ___________________

School, A brief description of the activity follows:

Name of Event:

Destination:

Designated Supervisor of Activity:

Date and Time of departure:

Date and Anticipated Time of Return:

Method of Transportation:

Student Cost:

If you would like your child to participate in this event, please complete, sign and return

the following statement of consent and waiver of liability.

My child has special medical concerns. Yes ______ No______

(if Yes, please describe on back)

CONSENT AND WAIVER

I herby request the participation of my child, ___________________, in the event

described above. I understand that this event will take place away from the school grounds

and that my child will be under the supervision of the designated school employee on the

stated dates. I further consent to the conditions stated above on participation in this event

includeing the method of transportation.

I hereby agree, on behalf of the named student and his/her other parent or legal guardians, to

waive any claims for liability against this school, the Diocese of Harrisburg ( and any diocesan

or school officers, agents or employees) which my arise from the participation of the named

student in the above-described event.

______________________________

(Print Parent’s Name

______________________________

(Parent’s Signature)

______________________________

(Date)

Please return this form by_____________________________.