* 1. Please provide the following information:

* 2. I, the parent/guardian listed above, grant permission for my child(the participant listed above) to participate in the following event with youth ministry.  I understand that my child will be under the supervision of parish staff and or volunteers.  

* 3. In addition to this form, the Diocese of Richmond requires an annual Medical Release Form to be on file for your child.  Do you have a medical release form on file?

* 4. I also allow the participant listed above to have photos taken of them.  I understand that the photo's taken may be posted on social media sites.  I am aware of the St. Therese Youth Ministry Facebook page and Instagram account.  I acknowledge that I have been informed of the handler names so I may follow if I so choose.

* 5. I, certify that as the parent/legal guardian of the participant listed above, I remain legally responsible for any personal action taken by my child.  I agree to hold harmless the Church of St. Therese and the Diocese of Richmond as well as its officers, directors, agents, chaperones, or representatives associated with this event, arising from or in connection with my child attending this event, or including but not limited to accidents, emergencies, exposures to reckless conduct of persons.  I also understand that if any medical changes occur during this time frame, I am responsible for updating my medical release form with the parish.  I understand that submission of my name, parishioner number, and today's date constitutes a legal and binding electronic signature.

T