Consent & Release of Liability
I, the parent/guardian of Participant Name(s), hereby give my permission for his/her participation in the Holy Name of Mary Faith Formation 2021-2022 program onsite and/or online.

As a condition of participating in this activity, I hereby hold harmless, release and discharge The Roman Catholic Archbishop of Los Angeles, a corporation sole, Archdiocese of Los Angeles Education & Welfare Corporation, Holy Name of Mary Church, and the Congregation of the Sacred Hearts of Jesus and Mary, their respective agents and employees and any parent/volunteer/chaperone, from any and all liability, loss or claims for personal injuries, wrongful death or property damage that I or my child may suffer as a result of participation in the Faith Formation program.

I give permission to the responsible staff members, chaperones, medical practitioners and medical facilities to use their judgement in obtaining and providing medical treatment for my child should it become necessary to do so. I understand that health insurance benefits through Holy Name of Mary Church, if any, may have limited application, and that I am entirely responsible for the cost of all medical treatment provided to my child. I agree to reimburse Holy Name of Mary Church for the cost of any medical treatment and related expenses incurred.

Photo and Video Release 
I hereby authorize Holy Name of Mary Church to use my child’s image, voice, name and/or work (“Personal Information”). I grant permission for photographs and/or videos of my child(ren) to be taken during Faith Formation activities and possibly used for noncommercial purposes including, but not limited to, publicity or promotion in print (e.g. in the bulletin or church displays), electronic media, such as the church AV system, social media and/or on the Holy Name of Mary website.

I understand and agree that Holy Name of Mary Church shall be the owner of all rights, title and interest, including copyright, in the photographs, electronic recordings and Materials.
Holy Name of Mary Church will not use the Personal Information for improper purposes or in a manner inconsistent with the teachings of the Roman Catholic Church. I hereby waive, release and discharge any and all claims, demands, or causes of action against Holy Name of Mary Church and its affiliated entities, employees, agents, contractors and any other person, organization, or entity assisting them with the photography, electronic recording or Materials, for damages or injuries in any way related to, or arising from the photography, electronic recording or Materials, or the use of the Personal Information, and I expressly assume the risk of any resulting injury or damage.

Please include name(s) of child(ren) in Faith Formation Program:
Participant Name(s)*  

Please print name and provide signature:
Printed Parent/Guardian Name*      Parent/Guardian Signature*   
Date Signed*   

*For Grades 1-12 ONLY

The Office of Safeguard the Children for the Archdiocese of Los Angeles is once again providing the "Empowering God's Children & Young People©" Safety Program to all schools, Religious Education Programs and Youth Ministry, grades 1-12. The program focuses on empowering children and young people with the knowledge, understanding and tools they need to keep themselves safe from abuse. 

Year 2: Boundaries & Bullying will be taught to our Gr 1-12 students between the months of February-March 2022 . The lessons include the VIRTUS® Introductory Video "Empowering God's Children," a variety of classroom activities, a Parent/Child Take-Home activity, and a "Catechetical Connection" to the Catechism of the Catholic Church to magnify God's desire for the happiness, health and safety of all children and young people.

Also included is a lesson on Summer Safety to be presented to classes at the end of each school year to remind our students to put "Safety First." 

If you would like additional information regarding “Empowering God's Children &Young People©" Safety Program, or if you would like to review the materials/videos, please feel free to contact Melanie Bailey at 909-599-1243 x232 or you may visit the Safeguard the Children website at www.archla.org/safeguard.

Holy Name of Mary Faith Formation

Gr 1-12

Parent Permission Slip for the Safety Program

I understand that this form must be completed electronically by October 29, 2021 for my child to participate in the "Empowering God's Children & Young People©" Safety Program class lesson for grades 1-12. My signature below is authorization of my permission for my child’s participation.

If my child is in the preschool/kinder Sunday School program, I understand that they will not have this lesson for the 2021-2022 Faith Formation Year.

Please include name(s) of child(ren) in Faith Formation Program:
Participant Name(s)*  

Please print name and provide signature:
Printed Parent/Guardian Name*   Parent/Guardian Signature*   
Date*