Name of Student: _______________________________

                             (Minor)

Age: ___________________

Program Site:

St. Cecilia Catholic School

5313 Madison Pike

Independence, KY  41051

Parent/Guardian:

I, the undersigned, in return for allowing Minor to participate, on behalf of Minor and for myself, hereby waive, release, and discharge any and all claims for damages for personal injury, disability or property damage of any kind, or death, which may hereafter accrue to Minor or myself as a result of his/her participation in beginning tumbling class at St. Cecilia Catholic School.  This release is expressly intended to discharge in advance St. Cecilia Catholic School, St. Cecilia Roman Catholic Church, The Diocese of Covington, Kentucky, and any employees, agents, and all parent volunteers involved in the beginning tumbling class from and against any and all liability arising out of or connected in any way with Minor’s participation in this activity.  This Wavier and Liability Release shall apply to Minor and me, as well as any of our heirs, executors, or administrators.

By my signature below, I hereby certify that I am the parent or legal guardian of Minor and that I am acting in that capacity.  Further, I acknowledge that I have read this document and understand its contents.

____________________________________________    ________________________

Signature of Parent/Guardian                                                       Date

____________________________________________

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