Từ 9 giờ 30 am 06/04/05 tại
Natural Bridge State Beach
Đến 4giờ 30 pm
Childs full name:.....................................................................................................
Address :
..Apt
:
..
City
..Zip
Code Ca
Daytime telephone
..Evening
telephone:
Fax :
E-mail
..
Health Insurance Company :
Policy #
.
In emergency, person to be contacted :
.. telephone
#:
Pledge -
I,
freely choose to join in the group of Them Suc (St.
Patrick Chieu) to picnic at Natural Bridge State
Beach (Santa Cruz, CA) I, on behalf of myself, my heirs, assigns, executors and
personal representatives, release, hold harmless and discharge forever the
Roman Catholic Church, the Diocese of San Jose, the Vietnamese Parish, the
Christian Brothers, their staffs and their officers, leaders, chaperons,
sponsors, agents, promoters, and affiliates from any and all liability, claim,
loss, damage, cost or expense and waive any claims against any such person or
organization arising directly or indirectly from and attributable in any legal
way to any action or omission to act of any such person or organization in
connection with the sponsorship, organization and services relating to these
events. I pledge obedience to all
the rules of the group.
Con em
kύ tκn, Students signature:...........................................................
In case of emergency, I, the
parent of the above mentioned child, give the
permission to any any hospital or to any physician
selected by the chaperon to render medical treatment deemed necessary and
appropriate. Any resulting hospital, medical or related costs and expenses will
first be paid by the medical insurance or benefit plan of mine
or my spouse. I also agree with the above pledge of my child.
Họ vΰ tκn
Cha hay Mẹ,
Parents name:.............................................................................
..., 2005