MEDICAL RELEASE/PERMISSION FORM
St. Catherine’s Youth Program

The undersigned parent or legal guardian of ___________________________________, a minor child, does hereby grant permission for the said child to engage in youth events at St. Catherine’s.  I release and hold blameless St. Catherine’s and the chaperones present at all youth events.

This consent also includes specific permission hereby granted to the adult supervisors and chaperones to make medical decisions with respect to the said minor child in the event of accident or injury when parental consent shall be unavailable or when circumstances shall require immediate medical decision, and to administer medication when required.

Dates this _____________ day of ________________, 2003.

__________________________________________________
Parent or Guardian’s Signature

MEDICAL INSURANCE INFORMATION

Company _______________________________    Policy Number _______________________________
 


PARTICIPANT INFORMATION

Name _______________________________    Name preferred _________________________________
Sex _____________________  Birthdate ________________________  Phone # ___________________
Address _________________________________________________________________
              Street                                                        City                             State      Zip Code
Allergies/required medications/dietary needs _______________________________________________
 

PARENT/GUARDIAN INFORMATION

Name ________________________________________________________________
Address(s) ______________________________________________________________
______________________________________________________________________
Home Phone(s) ______________________________________________________________________
Work Phone(s) ______________________________________________________________________
Cell Phone(s) ________________________________________________________________________

Person to notify in case of Parent/Guardian cannot be reached:
Emergency Contact Name(s) _____________________________________________________________
Relationship __________________________________________________________________________
Address __________________________________________________________________________
______________________________________________________________________
Home Phone ______________________________________________________________________
Work Phone ______________________________________________________________________
Cell Phone ________________________________________________________________________