Parent Signature Form

- Religious Education

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- Student(s) First and Last Name REQUIRED Please fill out this field. Please enter valid data.
- Consent to the release of the following personally identifiable information.
  
  CHILDREN, YOUTH AND ADULTS – PERSONALLY IDENTIFIABLE INFORMATION RELEASE FORM (5126.1 POLICY)
  
  The following release form must be signed and dated by the parent of a student prior to releasing personally identifiable information as defined in Policy 5126.0. The release is to be printed on parish letterhead.
  
  PARENTS’ CONSENT FOR RELEASE OF PERSONALLY IDENTIFIABLE INFORMATION
  
  The undersigned parent(s)/guardian(s) of ___(Student Name)____, a student in the parish school of religion program at St. Joseph Catholic Church (Plain City, OH) hereby Consent to the release of the following personally identifiable information.
  
  Specific information to be released:
  • Photos. If name is used in conjunction with photo, it will be first initial, last name.
  
  Reason for release:
  • PSR Activities published within the parish and in the Diocese of Columbus.
  
  Information to be released via:
  • Parish website and bulletin and in the Catholic Times of the Diocese of Columbus.
  
  The undersigned consent to the transfer of the above information to a third or subsequent party.
  I Agree Please select this field.
- PARENT HANDBOOK – I have read and understand the Parish School of Religion (PSR) Parent Handbook and that I can refer to it at any time by visiting the PSR area on the St. Joseph website.
  I Agree Please select this field.
- 4116.15 HARASSMENT POLICY — PERSONNEL
  
  I, _____parent/guardian________, a parent/guardian of a youth participant have received copies of the diocesan policy on harassment. I understand that it is necessary that any complaint of harassment must be filed with the (a) program administrator, (b) pastor or (c) diocesan director of religious education. I have had an opportunity to read the policy and am confident I understand the content and purpose.
  I Agree Please select this field.
- 5140.05 HARASSMENT POLICY — CHILDREN AND YOUTH
  
  I, _____parent/guardian_________, a parent/guardian of a youth participant have received copies of the diocesan policy on harassment. I understand that it is necessary that any complaint of harassment must be filed with the (a) program administrator, (b) pastor or (c) diocesan director of religious education. I have had an opportunity to read the policy and am confident I understand the content and purpose.
  I Agree Please select this field.
- Please fill out either section below, according to your wishes:
  
  Consent for Emergency Treatment
  
  Non-Consent for Emergency Treatment section.
- 1. CONSENT FOR EMERGENCY TREATMENT
  
  At the time of an emergency, in the event reasonable attempt to contact me have been unsuccessful, I hereby give my consent or any treatment deemed necessary by the preferred listed doctor or dentist, or in the event the listed doctor/dentist is not available by another licensed physician or dentist. I also agree to the transfer of my child(ren) to any reasonably accessible hospital where further consent will be obtained before treatment.
- Preferred Doctor Please enter valid data.
- Doctor's Phone Number Please enter valid data.
- Preferred Dentist Please enter valid data.
- Dentist's Phone Number Please enter valid data.
- 2. NON-CONSENT FOR EMERGENCY TREATMENT
  
  I do not give my consent for emergency medical treatment of my child(ren). In the event of illness or injury, I wish St. Joseph Church to take the following actions:
- Alternate Actions Please enter valid data.
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- Parent/Legal Guardian Full Name Digital Signature REQUIRED Please fill out this field. Please enter valid data.
- Today's Date (Month, Day, Year) REQUIRED Please fill out this field. Please enter a date.
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Parent Signature Form

Please fill out either section below, according to your wishes: