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CCD-Parental Authorization & Release Form

I give permission for my child to take part in the St. Patrick Religious Education/CCD activities on and off church grounds. In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify, and agree to hold harmless the Diocese of Corpus Christi and St. Patrick Church, its agents, employees and officers, and the chaperones, leaders, organizers, sponsors, and persons transporting our child to and from these activities. Neither the Diocese of Corpus Christi nor St. Patrick Church nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of this activity. I, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance. In the event of an emergency and I cannot be contacted, I hereby authorize that emergency treatment may be administered.

Contact Information
Parent/Guardian Name
  •  
Address
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E-mail
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Cell Phone --
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Home Phone --
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Child #1 Information
Child's Name
  •  
Child's Date of Birth //
  •  
Grade Level
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What medications does your child currently taking or takes regularly?
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If necessary, may we give your child Tylanol and/or Imodium?
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Does your child need to carry an EPI pen for Anaflactic Shock?
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I give permission to St. Patrick Religious Ed/CCD permission to post appropriate photos of my child on the St. Patrick website, promotional flyers and/or in the bulletin?
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If you only have ONE child, skip to Signature Section. If more than ONE child, continue to fill out for EACH child. Please fill out ALL Fields for each child.
Child #2 Information
Child's Name
  •  
Child's Date of Birth //
  •  
Grade Level
  •  
What medications does your child currently taking or takes regularly?
  •  
If necessary, may we give your child Tylanol and/or Imodium?
  •  
Does your child need to carry an EPI pen for Anaflactic Shock?
  •  
I give permission to St. Patrick Religious Ed/CCD permission to post appropriate photos of my child on the St. Patrick website, promotional flyers and/or in the bulletin?
  •  
Child #3 Information
Child's Name
  •  
Child's Date of Birth //
  •  
Grade Level
  •  
What medications does your child currently taking or takes regularly?
  •  
If necessary, may we give your child Tylanol and/or Imodium?
  •  
Does your child need to carry an EPI pen for Anaflactic Shock?
  •  
I give permission to St. Patrick Religious Ed/CCD permission to post appropriate photos of my child on the St. Patrick website, promotional flyers and/or in the bulletin?
  •  
Child #4 Information
Child's Name
  •  
Child's Date of Birth //
  •  
Grade Level
  •  
What medications does your child currently taking or takes regularly?
  •  
If necessary, may we give your child Tylanol and/or Imodium?
  •  
Does your child need to carry an EPI pen for Anaflactic Shock?
  •  
I give permission to St. Patrick Religious Ed/CCD permission to post appropriate photos of my child on the St. Patrick website, promotional flyers and/or in the bulletin?
  •  
FORM WILL NOT BE SENT UNLESS YOU CLICK ON THE SUBMIT BUTTON
Signature
Parent/Guardian Signature
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By typing your name here, you are agreeing to the above.
Date //
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Security
Spam Capture For security purposes, please enter the text that appears in the box below.
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