Medical Permission From (Youth Participant)
Your signature at the end indicates your consent and acceptance of the provisions included in this document.
- PLEASE PRINT -
Child’s Name______
Parish______Town ______
Age ______Sex ______Home Phone ( ) ______
Work Phone: Father ( )______Mother ( )______
Mailing Address ______
City, State & Zip______
SS# ______(necessary for emergency health care in most hospitals)
PARTICIPATION CONSENT :
I, (Name of Parent or Guardian) ______grant permission for my son/daughter to participate in the [ADD DESCRIPTION OF EVENT](the “Event”) during[ADD TIME PERIOD] , in accordance with all terms included in the accompanying “Parental/Guardian Consent , Release and Indemnification” form.
STATEMENT OF HEALTH (check one):
___I hereby warrant that, to the best of my knowledge, my child is in good health and able to participate in all Event activities.
___I hereby warrant that, to the best of my knowledge, my child has the following condition(s) and/or limitations and may not participate in the following activities(attach separate sheet if necessary):
______
______
______
insurance information
Family Health Insurance Co.: ______Policy No. ______
MOST RECENT PHYSICAL EXAMINATION (Please provide the following information regarding your child's most recent examination)
Date of Examination: ______
Physician or Clinic: ______Phone ( )______
Physician/Clinic Address______
IMMUNIZATIONS: (Please provide date of latest tetanus immunization) ______
MEDICATIONS: Any medications brought to the Event should be clearly labeled and in their original container. Please list any prescription or approved non-prescription drugs your child is presently taking. Include product name and physician's instructions on dosage and frequency.
______
Iunderstand that all prescription medication will remain in the possession of the adult team leader and be dispensed as prescribed.
I do/do not (circle one) grant permission for non-prescription medication (such as ibuprofen, Tylenol, throat lozenges, cough syrup) to be given to my child, if deemed advisable.
If there are any non-prescription drugs you do not want administered to your child please list them:
______
ALLERGIES Does your child have any known allergies? Yes/No (circle one). If yes, please attach a statement noting all known allergies, including how the child has been treated and with what medication. If medications are needed occasionally or regularly, please send them with your child in case of need.
OPERATIONS OR SERIOUS INJURIES (Within the past 18 months)
Operation/Injury ______Date ______
COMMUNICABLE DISEASES: Please notify your parish contact person [ADD NAME AND PHONE NUMBER] immediately if your child has been exposed to any communicable disease (mumps, measles, chicken pox, etc.) within three weeks prior to attending the Event.
MEDICAL EMERGENCY:In case of medical emergency, I understand that a reasonable effort will be made to contact parents or guardian of participants. In the event that I cannot be reached, I hereby give permission to the physician selected by the diocesan director or parish adult leader to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for, my child, as named herein.
HOLD HARMLESS AGREEMENT: I, (Name of Parent or Guardian)______covenant and agree to defend, protect, indemnify and hold harmless the Diocese of Rockville Centre, the Bishop thereof, the DRVC Youth Ministry,the parish of [ADD NAME OF PARISH], and their respective trustees,officers, employees, volunteers and authorized agents from and against each and every claim, demand or cause of action and any liability, cost or expense (including reasonable attorney’s fees) on account of any bodily injury (including death) to my child or any other person, damage or loss caused by, arising out of, or in any way incidental to or in connection with the information that has been provided herein or the acts or omissions of any Indemnitee hereunder taken in reliance thereon.
SIGNATURE OF PARENT OR GUARDIAN
I certify that the above information is correct and give permission for the release of medical recordsand information to an attending physician or other health care professional in case of injury or illness.
I fully understand the consequences of the foregoing statements and sign this form knowingly, freely, and willingly. (Your signature must appear below or your child will not be permitted to participate in the Event.)
Signature ______Date ______
Print Name: ______