Loading...

Contact Permission Form

Telephone Consumer Protection Act (TCPA) Compliance

Divine Redeemer

In compliance with the Telephone Consumer Protection Act (TCPA), the Diocese of Greensburg's Office of Information Technologies and Office for Catholic Schools are asking every parent/guardian and faculty member to complete and sign this Contact Permission Form.

  • If you give your permission to be called using automatic dialing equipment, including SchoolMessenger, please choose "Yes" from the permission dropdown box below and provide at least one phone number to which you wish to receive said automatic calls.
     
  • If you do NOT give your permission, please choose "No" from the permission dropdown box below. The phone number(s) you provide will therefore be blocked from receiving automatic calls, including SchoolMessenger.
First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
11 Participant's Name

First Name*

Middle Name

Last Name*
11 Participant's Date of Birth*
11 Participant's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Parent or Guardian's Email Address

Email*

Confirm Email*
Student(s) Full Name

If you are a parent, please provide the full name(s) of your child(ren) attending the school.


First Middle Last

First Middle Last

First Middle Last
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Permission

Choose "Yes" or "No" from the dropdown box.

Provide at least one mobile phone number.


Phone 1 (555-555-5555)*

Phone 2 (555-555-5555)
Parent or Guardian's Signature
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.

Agree To This Document
Tip: You need to complete your signature. Click here to return to the signature pad.
Do not print this document. Fill it out online and it will be delivered electronically.



Powered by Smartwaiver