All Saints Parish

All Saints Parish

Madison Lake, Minnesota

Office of Faith Formation & Youth Ministry

There must be a copy of this form for each student

Child’s Name ______Parish ______

Address ______Phone ______

School ______Grade ______Date of Birth ______

Parent/Guardians Name ______Home Phone ______

Address ______Work Phone ______

Cell Phone ______Email ______@______

IN CASE OF EMERGENCY NOTIFY PERSON OTHER THAN PARENT/GUARDIAN:

Name ______Phone ______

Health & Medical Information

Family Physician ______Phone ______

Address ______

Do you authorize the adult leader to authorize medical treatment for your child in an emergency, as considered necessary

by the attending physician? YES NO

State any reason why you do not want medical care given to your child in an emergency: ______

List all conditions for which your child requires ongoing medication and state the type of medication given:______

______

Has your child had difficulty with the following (circle any that apply)

Asthma Fainting Spells Convulsions Diabetes Heart Eyes Ears

Nose Throat Lungs Digestion Other ______

List any physical restrictions based on medical conditions:

______

Allergy to any food or medications: Yes No List: ______

Signature: ______Date: ______