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: ____________________________ (Printed name of parent or
guardian)
SIGNATURE: _______________________________________
DATE___________
COMPLETE ADDRESS:
__________________________City_________ Zip_______
PHONE NUMBERS:
Day# ______________________ Night# ____________________
EMAIL: ____________________________________
WITNESSED BY:
_____________________________________________________
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