* 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 events checked below. I understand that these events will take place under the guidance and direction of parish employees and/or volunteers from the parish:

* 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 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.Thérèse 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 limied to accidents, emergencies, exposures to reckless conduct of persons. Ialso 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.

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