* Required

Bowl America Fairfax 9699 Lee Hwy, Fairfax, Virginia 22031 703-273-7700
6:30-8:30pm on Sunday, Jan 22nd.
Cost: $20
Includes: Pizza, Soft Drinks, Shoe Rental, Unlimited Games

Please designate an emergency contact who is not the parent/legal guardian. In a medical emergency or unscheduled dismissal, parents/legal guardians will be contacted first. If parents/legal guardians are NOT available, then the emergency contact has medical consent and dismissal release authority.

Parental Permission and Liability Release: As parent/legal guardian of the participant names above, I give my permission for my children listed above to participate fully at Our Lady of Good Counsel Youth ministry event. I understand that children will be well supervised, and I will not hold Our Lady of Good Counsel Parish, its employees, or volunteers responsible if an accident should occur.

.I agree to indemnify and hereby release the Most Reverend Michael F. Burbidge Bishop of the Catholic Diocese of Arlington and his successors in office, as well as the Catholic Diocese of Arlington and all Diocesan clergy, employees, volunteers, and participating parishes and schools from any and all liability, claims, demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned of the participant resulting from said participant’s involvement in the above mentioned event (including transportation to and from the event). Furthermore, I on behalf of the participant hereby assume all risk of personal injury, sickness, death, damage, and expenses resulting from said participant’s involvement in the above described event.

Informed Consent to Medical Treatment: I request that in my absence the above-named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor. I assume full responsibility for all costs of such treatment. Further, should it be necessary for the participant to return home due to medical, disciplinary, or other reasons, I do hereby assume responsibility for the participant’s transportation home and any costs related thereto.

Photo, Press, Audio, and Electronic Media Release: I authorize OLGC Youth Ministry to use and publish my child’s photograph, video and/or audio recording along with their name identifying them for educational, news stories, illustration and/or marketing purposes.

I understand and hereby agree to the terms and conditions of the participant’s involvement in the above described event and I freely execute this Acknowledgement with full knowledge of its content.

The electronic signature below is treated by Our Lady of Good Counsel Parish as a physical, handwritten signature on a paper document.

To Bring: $20 check/cash made out to OLGC Youth Ministry