DISCLOSURE, AUTHORIZATION AND CONSENT FOR SOCIAL MEDIA OR OTHER ELECTRONIC COMMUNICATION INVOLVING MINORS

DISCLOSURE, AUTHORIZATION AND CONSENT FOR SOCIAL MEDIA OR OTHER ELECTRONIC COMMUNICATION INVOLVING MINORS

St. Mary of the Lake Catholic Church
I am the parent or legal guardian of
(full name of minor) (“My Child”).*

First NameLast Name
In order to ensure transparency and parental involvement, St. Mary of the Lake Catholic Church has created this consent form so that parents and guardians may provide authorization for St. Mary of the Lake Catholic Church leaders to electronically communicate with minors. Such communications must comply with applicable St. Mary of the Lake Catholic Church policies, including restrictions on private communications with minors.

I grant permission for staff or other leaders of St. Mary of the Lake Catholic Church to communicate with My Child electronically. I understand that such communications are for St. Mary of the Lake Catholic Church purposes only and may involve group communications relating to St. Mary of the Lake Catholic Church activities. Further, I understand and authorize that such electronic communications may be made via text, email, telephone and cell phone, social media, digital networking, and other electronic means.

I acknowledge that to review or receive public communications shared via social media with My Child, I will need to have an account with the same social media platforms or become a fan or follower of the same social media. I also understand that communications may be accessible or viewable by others who are also fans or followers of the same social media.

This Disclosure, Authorizations, and Consent form is valid for one year.

If I choose to rescind this authorization and consent, I agree that I will St. Mary of the Lake Catholic Church in writing and that this rescission will not take effect until it is received by (St. Mary of the Lake Catholic Church.

I have read the above Disclosure, Authorizations, and Consent, have had the opportunity to consider their terms, and understand them. I execute this document voluntarily and with knowledge of its significance.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Cell Number*

Area CodePhone Number
Parent/Guardian Phone Number #2

Area CodePhone Number
Child Email Address
example@example.com - If would prefer email communications go to the parent/guardian, please repeat your email address.
Child Cell Number

Area CodePhone Number
By typing my signature below, I acknowledge and agree this electronic or digital signature is the legally binding equivalent to my handwritten signature. This electronic or digital signature has the same validity and meaning as my handwritten signature. By typing my signature below as guardian, I acknowledge and agree to the conditions above. Electronic Signature*

Clear
Please type your full name.*

First NameLast Name
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty: