St John the Baptist Parish,

Parish Office, Pjazza San Ġwann Battista

Xewkija, Gozo, XWK 1012
t. 2155 6793 e.parroccaxewkija@gmail.com

PARENTAL APPLICATION & CONSENT FORM

2018-2019
Date: ____________________

I, ____________________________ I.D. ______________________

resident at ________________________________________________________________________________________
confirm that I allow my son/daughter __________________________, born on _____/_____/_______
to be part of and attend the respective TEEN GROUP meetings and activities held at the
Parish Centre, Xewkija ,or elsewhere during the scholastic year 2019-2020.

Kindly note the following:

 Medical Conditions/Medications:  Other notes

______________________________________________________________________________________________________________

HOLD HARMLESS AGREEMENT

I, the undersigned, as person entrusted with the care and custody of the minor, understand that
participation in this group may involve certain risks. As person entrusted with his/her care and custody I
am giving consent for the minor, to participate in the named activities. I understand that participation in
the activities is entirely voluntary and requires participants to abide by applicable rules and standards of
conduct. I release the Gozo Diocese, the Xewkija Parish, the activity coordinators, volunteers, related
parties or other organizations associated with the activity from any and all claims or liability arising out
of this participation to which I must abide according to the rules, procedures and / or instructions. In case
of emergency I hereby give my permission to the medical provider selected by the adult leader in charge
to secure proper treatment for my child.

DATA PROTECTION ACT

I hereby give my consent to Xewkija Parish to use photographs and/or videos and personal data of my
teen for St. Margaret Centre’s private or public purposes. I don’t hold the Xewkija Parish responsible for
photos/videos taken by third parties without the leaders’ consent.

I also give my consent to be contacted on the info below by myself provided.

Telephone (home) number ___________________

Mobile numbers of father ___________________ mother _____________________
Email of father and/or mother__________________________________________________________________
Mobile Number of Child ______________________________

Parent/guardian signature _________________________________________