Author: Dion

Middle School Grades 6-8
Release and Consent Form for 2024-2025
St. Joseph Church, Charlton, MA
Diocese of Worcester, MA
Name_________________________________DOB___________Grade____
Address________________________________________________________
_____________________________________________________
Phone #______________________________Cell #_____________________
Parent E-mail address____________________________________________
The best way to contact Parent_____________________________________
Parent/Guardian:
I, ______________________, the undersigned give my son, daughter ___________________________, permission to attend any and all EDGE events that would be held at another location other than St. Joseph’s Church in Charlton, MA during the period of July 1, 2024- September 1, 2025. By signing this consent form, I also give my child, mentioned above, permission to attend EDGE at St. Joseph’s Church in Charlton, MA throughout that aforementioned time period.
I give permission for my son/daughter to be evaluated, diagnosed, treated and/or medicated in accordance with standard medical practice by licensed medical personnel should an emergency occur. I relieve the EDGE Director, chaperones/core members, St. Joseph’s Church in Charlton, MA, and the Diocese of Worcester, MA of all responsibility and consequences that may arise as a result of this treatment.
I will not hold the EDGE Director, St. Joseph’s Church of Charlton, MA, chaperones/core members, or the Diocese of Worcester, MA or any representative of any event liable in the event of injury/illness. Further, I agree to accept all financial responsibility as a result of the scheduling of any such treatment for an injury/illness.
My child agrees to abide by all the rules set forth by the EDGE Director, St. Joseph’s Church of Charlton, MA, and chaperones/core members for all events. I understand that neither the EDGE Director, nor the chaperones/core members, St. Joseph’s Church of Charlton, MA, or the Diocese of Worcester, MA will be held liable if my child fails to cooperate with the said regulations and that any infractions of these rules may result in immediate transportation home. If it is determined that the youth should be sent home, the parent/guardian will assume all expenses for return transportation.
Parent/Guardian’s Signature___________________________________Date___________________
Youth:
As a member of St. Joseph’s Church of Charlton, MA and the Diocese of Worcester, MA, I understand and agree to abide by the rules set up by the EDGE Director, chaperones/Core members and St. Joseph’s Church Charlton, MA for each and every event held in the time frame mentioned above. I also understand and agree that I and/or the EDGE Director or chaperones/Core members will have to notify my parent/guardian at the time of any serious infractions requiring my dismissal from any event. I also understand that I will be sent home at my own and or parent/guardian’s expense.
Youth Signature___________________________Date_________________________
Name____________________________________________ Grade _________
Medical Information (print clearly)
List allergies to food, medicine, insects, animals, etc.
My child is on the following medications---Dose/Time taken.
List and explain any medical conditions you think we should be aware of. i.e. diabetes, asthma, seizures, etc.
Insurance Carrier_______________________________________________________
Policy holder ___________________________________________________________
Policy #_________________________________________
Child’s doctor____________________________________
Doctor’s phone #________________________________
In case of emergency please notify (only if information is different than what is on the opposite side of this form)
Name_________________________________________________
Address_______________________________________________
Phone #_______________________________________________
Cell #_________________________________________________
Relationship to child____________________________________
1. Occasionally during an EDGE night the youth are offered candy, sweets and/or food (i.e. pizza, ice cream). If it is your desire that your child not participate in this offering, please indicate by checking here______.
2. On occasion your child may be photographed or videotaped for an EDGE related event and even used in our website or newsletter. You have the right to object to the publication of said pictures of your child.
If you do not wish for your child to be videotaped or photographed
Please check here______,
Parent signature ___________________________________ Date ____________
Please submit a photo of your child with this form. The photo will only be used by the Edge Director and staff to learn the names of the students and get to know them better.

Cash/check # _________ Amt. Pd. ________ Due _______
Each student in Edge OR 1st Lights - $60 (3 in lower levels - $120)
Please indicate on check which students are in what grade. Ability to pay is never a factor in whether a child can attend. Credit card payments are accepted as well.