CLOW Consent Form

Diocese of Portsmouth

Registered Charity No. 246871

Safeguarding Office

Parental Consent Form for Children’s Liturgy of the Word

Contact Person: Joanna Mirecka

Child's Full Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parental Email

Parental Name

First Name

Last Name

Parental Address Only complete if different from above

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parental Contact Phone number

(###)

###

####

Please tell us of any allergies, or if your child suffers from any learning difficulties, ailments and/or is taking any medication)

Declaration

I agree to my child taking part in the Weekly Children’s Liturgy of the Word in the Parish Hall and when the session is finished, I will allow the catechists to escort my child back in to Church.

Yes

Declaration

In the event of an illness or accident, every effort will be made by the event leader to contact me. If for any reason this is not possible I agree to my son/daughter receiving medication as instructed and any emergency medical treatment as considered necessary by the medical authorities present.

Yes