Forms | Alpine Academy of Rockford Logo
  • Diocese of Gary

  • Consent to Participate, Waiver, and Release

  • Participant Information

  • Parent Information

  • Emergency Contact Information

  • Event Information

  • Parish/Organization: _____________________________
    Activity: _______________________________________
    Place: Online Video Conferencing: ___________________
    Date of Activity: _________________________________
    Event Contact Number: ___________________________
    Adult Chaperone(s): ______________________________

  • Authorization and Waiver of Risk

  • Online Conferencing Safe Environment Guidelines and Code of Conduct

  • To create the safest online community, the following guidelines will be put in place during the online gathering.

    • Two, safe environment trained adults will participate during the online gathering. 
    • The online gathering will be recorded. The recording will be used for safe environment purposes only and will not be distributed or posted. 
    • The link to the online gathering will not be posted on social media sites and will only be distributed to participants after the activity release is signed and returned. 
    • The online gathering will be password protected. 
    • Parents and guardians are welcome to participate.
    • Broadcasting a video stream from the participants end is optional. Students are able to join the online discussion using only an audio connection if they wish.
  • Code of Conduct for Youth Participants:

    • Please dress as if meeting in person. Your clothing should be modest and appropriate (no pajamas, please).
    • Please make sure nothing inappropriate or unseemly is in your surrondings when broadcasting video and audio. 
    • Two-way streaming from a restroom is never aacceptable.
    • Please use care to join from a non-intimate setting such as a home-office or simular room.
    • Parents are invited and encouraged to attend if they would like.
    • Please know sessions are recorded for the safety of participants and leaders. 
  • Promotional Photographs

  • In the interest of promoting future activities, video and still photographs may be taken during this event. This form constitutes written
    permission for Child’s participation in the videotape and/or photographs, which may be used for future promotional efforts, including
    the Diocese of Gary website (names are not used in photos).

  • Authorization Signature

  • Diocese of Gary

    9292 Broadway, Merrillville, IN 46410 | (219) 769-9292

  • Should be Empty: