(Please print and complete this form and attach to Application)
 

I, __________________________________________, am the parent or guardian of _______________________________,who was born on _______, and who is an applicant for the JUDGE MARABLE STUDENT OF THE MONTH AWARD.

I understand that if my child is selected as a STUDENT OF THE MONTH, that he/she will be invited to visit the 68th District Court for a tour for 1/2 to 1 day and will "shadow" Judge Marable as he performs his official duties at the Court during the regular business hours of 8:30 am thru 5:00 PM, Monday thru Friday.

I also understand that if my child is selected as a STUDENT OF THE MONTH that Judge Marable and/or his Citizens Advisory Committee will provide a photograph and biographical information about the awardees to local newspaper, radio, and television outlets for publication or broadcast by way of a press release. The same information will also be posted on the www.judgemarable.net website.

I do consent and give permission for my child to visit the 68th District Court as well
As for his/her name and biographical information and photograph to be released to the news media and the www.judgemarable.net website. 

I hereby consent that my minor child participate in the above activities and I hereby
execute this agreement, waiver, and release on his/her behalf. I state that my child is physically able to participate in said activities. I hereby agree to indemnify and I agree to hold harmless Judge Herman Marable, Jr., the 68th District Court, the City of Flint and its employees, members of Judge Marable's Citizens Advisory Committee, and any of their assignees, for any loss, liability, damage, costs, or expense which they may incur as a result of the death or injury or property damage that my minor child may sustain while participating in said activities associated with Judge Marable's STUDENT OF THE MONTH program, or a visit to the 68th District Court.

NOTE: If you feel that your student is not mature enough to attend this event without your presence and/or discipline (e.g., has had emotional, behavioral, and/or disciplinary issues at school in the past) please do not send your student to the Court. 

I have read and agree to sign this consent form.

By,____________________________ (Print name of parent or guardian)

SIGNATURE: _______________________________________  DATE___________
COMPLETE ADDRESS: __________________________City_________ Zip_______
PHONE NUMBERS: day#______________________night#____________________
EMAIL:____________________________________
WITNESSED BY: _____________________________________________________