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Parent Release Form

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- This form to be used when dependent children are participating in a church supported or sponsored event.
  
  I hearby consent to participation by my dependent(s) as noted below:
- Date This Release Authorized REQUIRED Please fill out this field. Please enter a date.
- Event Information
  
  Name of Event REQUIRED Please fill out this field. Please enter valid data.
  
  METHOD OF TRANSPORTATION REQUIRED Please fill out this field. Please enter valid data.
  
  Designated Supervisor of Event REQUIRED Please fill out this field. Please enter valid data.
  
  Destination or Location of Event REQUIRED Please fill out this field. Please enter valid data.
  
  Planned Date Event Begins REQUIRED Please fill out this field. Please enter valid data.
  
  Planned Time Event Begins REQUIRED Please fill out this field. Please enter valid data.
  
  Planned Date Event Ends REQUIRED Please fill out this field. Please enter valid data.
  
  Planned Time Event Ends REQUIRED Please fill out this field. Please enter valid data.
- Parent / Legal Guardian Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Dependent(s) are eligible to participate in a parish-sponsored activity requiring transportation to a location away from the parish grounds. This activity will take place under the guidance and supervision of adult chaperones.
  By electronically completing this form, I acknowledge the following statement of consent and release of liability. As parent or legal guardian, I understand I remain fully responsible for the actions and conduct of your dependent(s).
  I understand that this event will take place away from the parish grounds and that my dependent(s) noted will be under the supervision of designated parish employees on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation.
  In consideration of my dependent being allowed to participate in this field trip, I hereby agree on behalf of myself and my dependent, to release Immaculate Conception Parish, the Roman Catholic Diocese of Marquette, and any and all affiliated organizations, their employees, agents and representatives, including volunteer drivers (collectively “Releases”) from any and all claims, including negligence, which may be asserted by me or my dependent, or on behalf of my dependent, arising from or relating to my dependent's participation in the field trip. In the event this release on behalf of myself and/or my dependent(s) is/are held to be invalid or any unenforceable, I hereby agree to indemnify and hold harmless Releases from any and all claims, including negligence, which may be asserted by me or my dependent(s), or on behalf of my dependent(s), arising from or relating to my dependents' participation in the field trip. This release or indemnification does not apply to claims for intentional misconduct or gross negligence; nor does this release or indemnification apply to the extent of commercial insurance coverage for any claim, but this Release or Indemnification shall apply to the extent of any self-insurance or deductible applicable to any claim.
  
  In consideration of the above provided information, I consent by this electronic acknowledgement/signature to the participation of my depedent(s) under this agreement.
  I Agree Please select this field.
- Emergency Contact (If Parent Cannot Be Reached)
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Relationship to Dependent(s) Please enter valid data.
- Enter Number of Dependents Authorized For Event/Field Trip REQUIRED Please fill out this field.
  
  Dependent 1
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
  
  Dependent 2
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
  
  Dependent 3
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
  
  Dependent 4
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
  
  Dependent 5
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
  
  Dependent 6
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
  
  Dependent 7
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
  
  Dependent 8
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
  
  Dependent 9
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
  
  Dependent 10
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Person Completing Form Please enter valid data.
Submit

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