Mother Daughter Retreat Release

Mother Daughter Retreat

Parental Release

* Indicates required field

Mother's Name *

First

Last

Email *

Phone Number *

Daughter's Name *

First

Last

Daughter's DOB *

Emergency contact name in case we can't reach you *

Emergency Contact Relationship to participant *

Emergency Contact Cell *

Insurance Provider *

Insurance Policy Number *

Family Doctor *

Please list any allergies or medical conditions we should be aware of. *

If an emergency arises regarding your child and you cannot be reached, do you give permission for medical treatment to be administered? *

Yes No

Do you consent for your child to be in photos and videos that may be used for promotion and publication? *

Yes No

Do you consent to the parental release below? *

Yes No

I give permission for my child to participate in the Mother Daughter Retreat. I will not hold St. Lawrence Parish, it’s employees or volunteers liable if any harm should occur to my child.

I agree on behalf of myself, my child registered herein, or our heirs, successors, and assigns, to hold harmless and defend St. Lawrence Parish, its officers, directors, employees and agents, and the Archdiocese of Mobile, its employees and agents, chaperones, or representatives associated with the event, from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the parish, its officers, directors and agents, and the Archdiocese of Mobile, its employees and agents and chaperones, or representative associated with the event for reasonable attorney’s fees and expenses that may occur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the parish/Archdiocese.

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