EVENT NAME: SHINE YOUTH RALLY
DESTINATION: WEST CATHOLIC HIGH SCHOOL
ACTIVITY SUPERVISOR: STEFANIE IWAN . 616-340-0596
DATE/TIME: SATURDAY, MARCH 24TH 2PM-8:30PM . $25 before 3/23 or $35 cash at the Door
METHOD OF TRANSPORTATION: PARENT
Phone Number During Event
I am available to chaperone
Please list doctor's name and phone number any allergies, medications or pertinent comments
Health Insurance Data
Company, policy, group and contract
Please type your name to certify above Statement of Consent
Statement of Consent
I hereby consent to participation by my child(ren) in the event described above. I understand that the event will take place away from the school/parish grounds. I further consent to the conditions stated above on participation in this event, including the method of transportation. In consideration of my child being allowed to participate in this event, I agree to waive and release, and indemnify and hold harmless Immaculate Heart of Mary School/Parish, any and all affiliated organizations, its/their employees, agents, representatives, volunteers and drivers, from any and all claims I or my child may have, excluding claims for intentional misconduct or gross negligence, arising from or relating to my child’s participation in this event. I authorize Immaculate Heart of Mary School/Parish to obtain necessary medical treatment for my child in case of illness, injury or accident. This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence. I grant to IHM Parish/School my consent without reservation to use, assign, convey, reproduce, copyright, publish or sell my/my child's name, voice and/or image that arises from participation.
I certify that I am the custodial parent legal guardian of the minor child named above, and I agree to the above terms for myself and for my minor child.
Send me a copy of my responses.
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