RE-Parental Authorization & Release Form

I give permission for my child to take part in the St. Patrick Religious Education activities on and off church grounds. In consideration of the opportunity for my child to participate and fully recognizing that such an undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify, and agree to hold harmless the Diocese of Corpus Christi and St. Patrick Church, its agents, employees and officers, and the chaperones, leaders, organizers, sponsors, and persons transporting our child to and from these activities. Neither the Diocese of Corpus Christi nor St. Patrick Church nor any of said persons shall be held financially responsible for any injury, illness, or death incurred as a direct or indirect result of this activity. I, the undersigned, have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance. In the event of an emergency and I cannot be contacted, I hereby authorize that emergency treatment may be administered.

INFORMATION

Submit for each child	PLEASE FILL OUT AND SUBMIT THIS FORM FOR EACH CHILD ENROLLED IN OUR PROGRAM!
Medical Matters	I hereby warrant to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Of the following statements pertaining to medical matters, sign only those in accordance with your wishes:
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 or doctor.

CONTACT INFORMATION

Parent/Guardian Name

First Name*

Middle Name

Last Name*

Address

Street 1*

Street 2

City*

State*

Zip*

E-mail

Required*

Cell Phone

Required* --

Home Phone

Family Doctor

First Name*

Last Name*

Doctor's Phone

Required* --

EMERGENCY CONTACT

Message

In the event of an emergency and you are unable to reach me, contact:

Name

First Name*

Last Name*

Phone

Required* --

Relationship to the Child/Children

Required*

CHILD'S INFORMATION

Child's Name

First Name*

Middle Name

Last Name*

Child's Date of Birth

Required* //

Grade Level

Required*

What medications does your child currently taking or takes regularly?

Required*

Medications

My child will bring all such medications, well labeled, that are necessary. Names of medications and concise directions for seeing that the child takes such medications, inculding dosage and frequency are as follows:

List Medication(s)

Please list all medications. If none, type N/A*

Dosage

Permission Any Medication Prescription or Not

I hereby DO NOT GRANT PERMISSION for medication of any type, whether prescription or non prescription may be administered to my child unless the situation is life threatening and emergency treatment is required.

I DO NOT GRANT permission

Please Type in your initials

If you do not want your child to receive any medication please initial.

Permission Non Prescription

I hereby GRANT PERMISSION for nonprescription medication (such as Tylanol/Advil, throat lozenges, cough syrup) to be given to my child, if deemed advisable. I understand that Asprin will not be given to my son/daughter.

EPI Pen

Does Your Child need to carry an EPI pen for Anaflactic Shock? *

Medical Conditions

(Diocesan personnel will take responsible care to see that the following information will be held in confidence.)

My Son/Daughter has had an episode of the following or has been diagnosed with:

	Siezures
	Asthma

	Diabetic
	NONE

Other

If diagnosed with any other medical condition, please explain

Allergies

Required*

My son/daughter has had Allergic reactions to the following (foods, dyes, latex, medications, etc.) If no, type NONE

Surgery

Required*

My Son/Daughter has had a medical surgery within the last six months?

Diet

Required*

My Son/Daughter has a Medically prescribed diet? (If no, type NONE)

Limitations

Required*

My Son/Daughter has the following physical limitations? (if No, type None)

Immunizations

Required*

My Son/Daughter's Immunizations are up to date?

Immunizations

Date of Last tetanus/diphtheria immunization

Special Medical Conditions

You should also be aware of these special medical conditions of my child.

Insurance Information

(Please send a copy of the Insurance Card, front and back, to mrswetish@hotmail.com

Insurance Carrier

First Name

Last Name

Name of Insured

First Name

Last Name

Insurance Policy Number

First Name

Last Name

Father's Name

First Name

Last Name

Father's Phone Number

Mother's Name

First Name

Last Name

Mother's Phone Number

If Child Becomes Ill

In the event it comes to the attention of the chaperones associated with the activity that my child becomes ill with repeated symptoms such as a headache, vomiting, sore throat, fever, diarrhea, I want to be called immediately. If this will be a long distance call, I want to be called collect (with hone charges reversed to myself). I fully understand the foregoing statements and sign this Parental/Guardian Medical consent Waver knowingly, freely, and willingly.

PHOTOGRAPHY/VIDEOGRAPHY CONSENT

Important! To be filled out by the Parent/Guardian for youth under 18 years of age. (If the participant is 18 years of age or older, consent must be signed by the individual)

Permission

I, the parent/guardian of the above mentioned child, grant St. Patrick's Religious Education and St. Patrick Church permission for my child to participate in activities that may be video taped and/or photographed I agree on behalf of myself, my child's other parent, our heirs, successors, and assigns, to release and hold harmless and defend the Diocese of Corpus Christi, the sponsoring parish (its pastor, youth minister, principal, volunteers, other agents, etc.) or any representatives associated with the scheduled activity from all damages, claims, suits, expenses and payments for injury to my child and/or property, including all damages, claims, suits, expenses and payments resulting from the negligence of the Diocese of Corpus Christi, and parish, and/or their officers, directors, volunteers, and employees.

I understand

As parent/guardian, I understand that promotional pictures (individual and group) will be taken during events/activities. I give permission for my son's/daughter's picture to be used for promotional materials (newsletter, web page, calendars, PowerPoint presentations, video, etc.) in highlighting the event.

Permission
Required*

Choose Yes or No*

	Yes
	No

Signature

Parent/Guardian Signature		By typing your name here, you are agreeing to the above.
Signature of Participant IF 18 years or Older		(Participant 18 years or older must sign own consent)
Date	//

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RE-Parental Authorization & Release Form

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