My Brother's Keeper parental consent form

Parent/Guardian consent form and Liability waiver
Event/activity*
Event/activity location*
Event date*

MonthDayYear
DateHourMinutesAM/PM Option
My Brother's Keeper volunteer*

First NameLast Name
Additional adult attending*

First NameLast Name
Participant*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Parent/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone*

Area CodePhone Number
Parent cell phone*

Area CodePhone Number
Parent Email*
I, Parent/Guardian's name* grant permission for my child,Child's name* to participate in this My Brother's Keeper activity/event than requires transportation to a location away from the parish site. This activity/event will take place under the guidance and direction of at least two adults; one from My Brother's Keeper and a volunteer from the parish, or the child's parent/guardian.
As a parent and/or legal guardian, I remain legally responsible for any personal actions taken by my child. I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and defend the Catholic Church of St. Ann, its directors and agents and the Archdiocese of Atlanta, chaperones or volunteers associated with the activity/event arising from or connected with any illness, injury or medical cost of treatment in connection with my child attending this event/activity.*

I agree
In signing this form, I the parent/guardian, certify that all information contained herein is true and accurate to the best of my knowledge. Please sign below:*

Clear
Today's Date*

MonthDayYear
Date
Each child must have a current medical release form on file before participating in off-site events.

After submitting this form, you will receive a confirmation email with a link to the medical release form. Fill out the online form, download and email to mybrotherskeeper.stann@gmail.com.

You may also access the form at st-ann.org/mbk.
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Parent/Guardian consent form and Liability waiver