Please list doctor's name and phone number any allergies, medications or pertinent comments

Company, policy, group and contract

Please type your name to certify above 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.