Faith Formation Medical Form and Media Release 2021-2022

Please complete one Medical/Media Release Form 2021 - 2022 for EACH CHILD you are registering in Catechesis of the Good Shepherd (CGS) or Youth Ministries. Thank you!

Child/Youth/Teen Information

I am filling out this form for:

Required*

Child's Name (Last Name, First Name)

First Name*

Last Name*

Child/Youth/Teen Email

ONLY IF APPLICABLE

Family Information

Parent or Legal Guardian Name

First Name*

Last Name*

Parent or Legal Guardian Phone Number

Required* --

Emergency Contact Person

First Name*

Last Name*

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

Required* --

Medical Information

All information on this form will be kept confidential and only used in case of medical need or emergency.

Medical Matters

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child *

CONSENT FOR EMERGENCY MEDICAL TREATMENT

In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. i wish to be advised prior to any further treatment by the hospital of doctor. *

Name of Parent or Legal Guardian giving Consent

First Name*

Last Name*

Today's Date

Required* //

Insurance Carrier

Required*

Policy Number

Required*

Primary Care Physician Name

Required*

PCP Phone Number

Required*

Medications

Please list any medications your child is currently taking, including dosage and purpose.

All information is confidential.

Chronic or special medical conditions

Please list any special medical conditions we should be aware of for your child.

All information is confidential.

Allergies, dietary restrictions, physical limitations, homesickness

Please list below any pertinent information, thank you.

All information is confidential.

In case of illness

If your child becomes ill with symptoms such as fever, headache, nausea, vomiting, sore throat or diarrhea, do you want to be contacted? *

OTC Medications

I hereby grant permission for non-prescription medication (i.e. non-asprin products such as acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate by an adult in charge. *

Contagious Disease Exposure

Has your child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? *

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.

Parent/Legal Guardian Name #1

First Name*

Last Name*

Parent/Legal Guardian Name #2

First Name

Last Name

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Faith Formation Medical Form and Media Release 2021-2022

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