2021-2022 PARENT / GUARDIAN CONSENT FORM
Important: both sides of this form are to be completed by the parent or legal guardian of children under
18 years of age in order to be considered
PRINT HERE THE NAMES & GRADES OF ALL THE CHILDREN ON THE REGISTRATION FORM
1_ 4
Name Grade (Fall 2021-2022 Name
Grade (Fall 2021-2022)
2_ 5
Name Grade (Fall 2021-2022 Name
Grade (Fall 2021-2022
)
3 _ 6_
Name Grade (Fall 2021-2022 Name
Grade (Fall 2021-2022
MEDICAL CONSENT
In the event of an emergency, I hereby give permission to the staff of St. Cecilia Catholic Church to seek
emergency
medical transport or treatment for my child/ren named below. I will be responsible for all costs
wish to be advised before further care is given by the hospital or doctor. If I cannot be reached,
Name & Relationship
Family Doctor
Insuranc
e Phone
Number
Chec
k
here if not insured
List medical conditions, medications, and life-threatening allergies: ___________________________
_____________________________________________________________________________________
In the event of any accident or injury,
I agree on behalf of myself, my child/ren other parent if known or
of parent) the child/ren named below, or our heirs, successors, and
to hold harmless and defend the Archdiocese of Galveston-Houston, its pastor or any representative
Faith Formation and Youth Ministry, unless the parties involved were careless and negligent.
Signature of Parent /Guardian Date __________________
VIDEO /PHOTOGRAPH CONSENT
As parent/guardian, I understand that promotional pictures and videos (individual and group) may be taken during
VBS, Faith Formation classes or Youth Ministry activities. I give permission for my child’s pictures (named below) to
be used for church promotional materials such as newsletters, web pages, calendars, Power Point presentations,
or videos to promote or highlight these classes or activities. My child’s name will not be released without further
consent.
Signature of Parent /Guardian Date __________________
CONSENT & LIABILITY WAIVER
I AM THE P
ARENT OR LEGAL GUARDIAN OF THE CHILD OR CHILDREN NAMED ABOVE. I HAVE
RECEIVED THE CCE POLICIES AND GUIDELINES HANDBOOK. I FULLY UNDERSTAND AND ACCEPT
THESE POLICIES AND GUIDELINES KNOWINGLY, FREELY AND WILLINGLY.
Primary Contact Number
Parent's Printed name: _________________________ Signature: _____________________
Phone:______________________
Phone:______________________
Phone: ___________________________
_____________________________
__________________________
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