PARENTAL PERMISSION AND MEDICAL RELEASE FORM

Please print. Thank you.

PARTICIPANT’S NAME_____________________________PHONE _________________________

ADDRESS________________________________________PHONE_________________________

CITY___________________________________STATE______________ ZIP__________________

PARISH________________________ BIRTH DATE____________ GRADE_______GENDER_____

PARENT/GUARDIANS’NAME_________________________HOME PHONE___________________

ADDRESS________________________________________WORK PHONE___________________

DOCTOR’S NAME__________________________________DR.’S PHONE____________________

INSURANCE COMPANY_____________________________ POLICY #_______________________

Are there any known allergies to food or medications that those who work with your young person on this weekend should be aware of? Yes No

If Yes, explain: ____________________________________________________________________

Are there any known physical, psychological or emotional limitations that would affect this young person’s participation in this event? Yes No

If Yes, explain: ____________________________________________________________________

EMERGENCY CONTACT IN THE EVENT THE PARENT (S) CANNOT BE NOTIFIED:

NAME ___________________________________________ PHONE_________________________

Release Form

I request that the Roman Catholic Diocese of San Jose, Office of Youth and Young Adult Ministries, permit my child to participate in the , to be held at the on _________________. I understand that reasonable precautions will be taken to safeguard the health and well being of my child, and that I will be notified as soon as possible in the event of an emergency. In case of sickness or accident, I authorize and consent to any x-ray exam, anesthetic, medical, dental or treatment and hospital care to be rendered to my child under the general care and advice of any physician, dentist or surgeon licensed to practice in any state. I further understand and agree to be responsible for any such medical, dental and/or hospital expenses incurred. I will provide the Diocese a copy of my child’s medical card prior to the event.

Parent’s Signature_______________________________________Date___________

OTHER Parent’s Signature_________________________________Date___________