As parent and/or guardian, I authorize treatment of the minor listed above by a licensed physician in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment or cause undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. This release is for the duration of the school year, September 2023 through May 2024. This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment emergency circumstances in my absence. 

By typing in your name below you are giving your signature and approval.

  Please write person's name, relationship to child, and home/cell number

 Parents are increasingly Concerned about their children's safety, and with good reason. The Diocese of Santa Rosa is committed to being a community that cares for children. Therefore, St. Mary’s Parish, in compliance with the diocese, is providing several opportunities for children, and their families, to learn more about preventing sexual abuse and how to guard against it. We will offer a class entitled Circle of Grace, which is a single session, and will be provided as part of their religious education curriculum.

  Please review the age appropriate materials for each grade level (Available through the Religious Education Coordinator). If you do not wish to have your child participate in this lesson, please Indicate below, and we will notify you in advance.