ST. MONICA PARISH SCHOOL SCRIP

RELEASE AND HOLD HARMLESS FORM

The undersigned hereby consents to their St. Monica Parish School Scrip being sent home from St. Monica Parish School with the person(s) designated below. The undersigned agrees to hold harmless and release St. Monica Parish School, it’s employees and volunteers from any loss or damage arising from or relating to the scrip being so delivered. This release and hold harmless is valid through 6/30/12 and may be revoked at any time by sending a written note to the St. Monica Parish School Scrip Coordinator.

YOUR NAME: _________________________________

ADDRESS: ___________________________________

YOUR SIGNATURE: ____________________________

DATE: _______________________________________

PERSON(S) DESIGNATED TO DELIVER ST. MONICA PARISH SCHOOL SCRIP:

IF DESIGNATED PERSON IS A STUDENT, GRADE OF STUDENT: _____

PERSON(S) DESIGNATED TO DELIVER ST. MONICA PARISH SCHOOL SCRIP:

PLEASE PRINT AND RETURN THIS FORM TO THE SCHOOL OFFICE