Liability and Media Form Parent/Guardian Name * First Name Last Name Child/Children's First and Last Names * Please list all the children that these releases apply to. Medical Release * If emergency treatment is required, and the parent/guardian cannot be reached immediately, your signature in the space provided below empowers parish authorities to exercise their own judgement to transport your child to a hospital emergency room. This is a general authorization and is not sufficient for the release of confidential information protected by Federal Law. Emergency Contact Name * In the event a parent cannot be reached, please provide us with an alternative contact. First Name Last Name Emergency Contact Phone Number * (###) ### #### Relationship of Emergency Contact to Child/ren * Social Communication Policy Please review the Safe Environment Social Communications Policy for the Diocese of Green Bay. www.gbdioc.org/docman/safe-environment/1247-office-of-safe-environment-digital-communication-policy-english/file * I have been made aware of the Safe Environment Social Communications Policy for the Diocese of Green Bay and any related local practices and guidelines concerning social communication. Permission for ministry representatives to digitally communicate with your child/children... Yes, I authorize communication with my child/children electronically, including via social media or other digital means, in accordance with the diocesan policy listed above by staff ministry representatives. No, I do not authorize communication with my child/children electronically. For High School and Confirmation Students, please add their email(personal, not school email) and text number if you wish for them to receive reminder emails, texts, etc. NOTE: In order for them to receive these, you must have checked Yes in the above question. Thank you. Media Release * This authorization constitutes permission for my child/children's participation in videotaping and/or photographs which may be taken during the program/trip. These could be used for further promotional videos, website promotions, fliers, or other diocesan or parish appropriate uses. After clicking the Submit button, you will be redirected to the payment page. Payments will be handled online this year. If you have any questions, please contact Becky at faith.formation@threecatholicchurches.com.
