PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER

Activity Consent

Participant’s name: _____________________________________________________

Birth date: ___________________________ Sex: ___________________________

Parent/Guardian’s name: ________________________________________________

Home address: _______________________________________________________

Home phone: ____________________ Business phone: _____________________

I_________________________________, request that the parish allow my/our son/daughter

     Parent or Guardian Name

______________________________________ (Child’s Name) to participate in this parish activity that may require transportation to a location away from the parish site. This activity will take place under the guidance and direction of parish employees and/or volunteers from St. Rose/St. Mary’s Parishes.

A brief description of the activity follows:

Type of Event:                                      ___________________________________________  

Date:                                                    ___________________________________________

Duration of activity:                            ___________________________________________

Location:                                             ___________________________________________

Mode of transportation to and from event: ______________________________________

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("participant"). I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend St. Rose/St. Mary Parishes

Its officers, directors and agents, and the Catholic Diocese of Green Bay, coaches, chaperones, or representatives associated with the activity for reasonable attorney’s fees and expenses arising in connection therewith.

Signature: _________________________________ Date: _______________________