Faith Formation Medical Form and Media Release 2019-2020

Please complete one Medical/Media Release Form 2019-2020 for EACH CHILD you are registering in CGS, Edge or Life Teen. Thank you!
 

Personal Information
I am filling out this form for...
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Select all that apply.
Child's Name
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Parent or Legal Guardian Name
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Parent or Legal Guardian Phone Number --
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Emergency Contact Person
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In the event of an emergency and we are UNABLE TO CONTACT PARENTS OR LEGAL GUARDIANS, please provide an alternate Emergency Contact Person.
Emergency Contact Phone Number --
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Medical Information
All information on this form will be kept confidential and only used in case of medical need or emergency.
Medical Matters
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CONSENT FOR EMERGENCY MEDICAL TREATMENT
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Name of Parent or Legal Guardian giving Consent
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Today's Date //
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Insurance Carrier
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Policy Number
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Primary Care Physician Name
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PCP Phone Number
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Medications
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All information is confidential.
Chronic or special medical conditions
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All information is confidential.
Allergies, dietary restrictions, physical limitations, homesickness
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All information is confidential.
In case of illness
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OTC Medications
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Contagious Disease Exposure
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Media Release
CONSENT I/We, the parent(s)/guardian(s) of the youth named on this form, authorize and give full consent, without limitations or reservation, to Holy Family Catholic Parish, to publish any photograph or video in which the above named student appears while participating in any program associated with Holy Family Catholic Parish and its ministries. There will be no compensation for use of any photograph or video at the time of publication or in the future.
I/We agree with the above statement.
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Parent/Legal Guardian Name #1
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Parent/Legal Guardian Name #2
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