Mariapolis 2020

Parental Consent Form Midwest Mariapolis 2020

This form allows you to submit parent/guardian consent and emergency contact for your child while he/she attends the Mariapolis.

I am the parent filling out this form. *

Yes

No

STOP: This form must be completed by the PARENT or other legal guardian of the child. If you are not the parent/guardian, please send a link to this form to the parent for completion.

Each child 17 years and under must have a parental consent on file during the Mariapolis. Thank you.

TRAVEL CONSENT

My son/daughter listed below has permission to travel with and in the care of the person as stated below for the purpose of attending the Mariapolis Convention of the Focolare Movement to be held at Lindenwood Retreat Center, Plymouth, IN, from Thursday, July 16, through Sunday, July 19, 2020. I/We understand that riders in the cars will be required to wear seatbelts.

PARENTAL PERMISSION

I release and discarge the Focolare Movement (Work of Mary) and anyone or any person representing the Focolare Movement (Work of Mary) in any capacity from any claim or cause of action whatsoever arising out of any injury or illness that my child might sustain as a result of participating in the program and activities sponsored by the Focolare Movement (Work of Mary) or as a result of being on the premises of the Focolare, even though caused as a result of facts whereby such individual or corporations would be responsible under principles of strict liability, negligence or any other theory of liability, except in the case of gross negligence.

In the event my child becomes injured or ill during the program, we authorize the guardian/responsible person named below to secure first aid and/or the services of any legally qualified physican or hospital, and we agree to assume any financial obligations incurred therewith.

MEDIA CONSENT

I authorize the Focolare Movement, during the Midwest Mariapolis, from July 16 to July 19, 2020, to take photographs and/or digital images of my child and publish photos and videos in which our son/daughter may be featured as well as articles containing the experience lived by my son/daughter:

On websites and other publications of the Focolare Movement and other affilitated entitites
In newspaper articles written by the Focolare Movement.

I authorize the use of these images without compensation to me.

All negatives, prints and digital reproductions shall be the property of the Focolare Movement.

Child's Full Name *

Responsible Adult that the child is traveling/attending with: *

Trip Begins on: * +

Arrival Date * +

Return Date * +

Return Destination *

Parent's Street Address *

City *

State *

Parent Home Phone *

Mother's Cell Phone *

Mother's Work Phone *

Father's Cell Phone *

Father's Work Phone *

Alternate Person (someone near to you who could contact you if you are not at home) *

Relationship *

Cell/Home Phone of Alternate Person *

Family Primary Care Physician *

Physician Phone *

Physician Address *

Insurance Company *

Insurance Policy # *

Insurance Group # *

SIGNATURE

By entering your name below, you, as parent/legal guardian, give consent and permissions as stated above.

Typed Signature of Parent/Legal Guardian: *

Date * +

PARENT's Email Address *

Use mouse or click and use your keypad or, use finger with touch screen to write your electronic signature.

Signature of Parent *

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