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School Advisory Committee Meetings – 2nd Tuesday of each month starting at 6:30 P.M.
PARENT/LEGAL GUARDIAN PERMISSION SLIP
AND INDEMNITY AGREEMENT
PLEASE Read and complete
Child/Ward ____________________________________________________
Parish/School St. Roman Betz Center (drop off in back parking lot)
Designated Supervisor of Activity: Michelle Zakula and Rae Ann Konkol
Activity: middle school dance
Date(s) and time of activity: Monthly dance-doors open at 6:30pm-9:30pm
Method of Transportation: OWN
COST: $6.00 and bring money for snacks and raffles!
Student notes: No gum chewing and appropriate/MODEST attire is required.
I consent to the participation of my child/ward in the above named activity. In consideration for my child/ward’s participation, I agree to reimburse and indemnify St. Roman Parish and School (understood to include the Archdiocese of Milwaukee) for all reasonable legal and court fees incurred by the parish/school in defending a lawsuit that I or my child/ward may bring against the parish/school which relates to the above named activity if St. Roman Parish and School is found not legally liable by the courts and prevails in the lawsuit. If St. Roman Parish and School is found legally liable for injuries sustained by my child/ward, this paragraph will not apply.
I certify that I have an understanding of this agreement and any risks and hazards associated with the activity that my child/ward will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the parish/school to clarify any concerns or questions about the activity or this agreement that I may have had.
______________________________ ___________________________
Parent/Legal Guardian Signature Date
______________________________ ___________________________
Address Home Phone /Work Phone
EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Name: ____________________________ Phone Number ____________________
Please furnish medical information about your child/ward, which may be pertinent to his or her participation in the above activity. _____________________________________
This form has been prepared by and is required by the Archdiocese of Milwaukee’s Protected Self-insurance Program. Questions should be directed to Catholic Mutual Group at 262-255-6906. Attention Molly Hatfield.