This medical release blank form is a document that demonstrates that a parent gives permission to allow medical treatment of their child if an emergency occurs in the parent’s absence. Every parent of a child wants to know with certainty that their children will receive prompt medical attention when they are apart from them. This form has several sections for information regarding 1)the child’s name, address, phone number, date of birth and parent/guardian’s name, 2) medical information, medications and dosage, medical insurance name, name of policy holder and relation to child, policy number and group number. There is also a full release statement that completely absolves the group that the child is in, in the parent’s absence and that group will be held to no financial responsibility for an event that occurs. This release also authorizes the group the child is with to allow emergency medical treatment. After this section, there is a place for emergency contact information if the parent is unavailable by phone. A medical release form is a form that almost every parent will encounter during their children’s school years.
PARENT /GUARDIAN CONSENT AND EMERGENCY MEDICAL RELEASE FORM Name off tthe Eventt:: MSG Fun Night after 5:30 Mass Name o he Even DATE : SEPT. 27 Designated Supervisor of Activity: Sue Marco Time . : 5:30 Mass - 9 pm Cost to Youth: $3.00 food/ supplies Bring forms and money that night- RSVP to office 897-7797 by the 25th or email@example.com by the 26th Name of Youth:____________________________________ Date of Birth__ ________ Grade______ Gender: Male__ _ Female ___ (check one) Home Address:__________________________________________ Parent / Guardian's Name:______________________________________________ Home phone:__ Work phone:___________ Cell phone:_____ MEDICAL INFORMATION Please list all information pertaining to allergies, diet, special medications, health conditions or any other information necessary in an emergency situation. Explain fully:______________________________________________________________________ Medications: My child is taking the following medication(s): Description: ________________________________Dosage: _____________________ Description:_________________________________Dosage:______________________________ Medical / Hospital Insurance _________________________________________________ Name of Policy Holder _____________________ Relation to participant __________________ Policy Number: ____________________________________ Group Number: ______________ If you would like your youth to participate in this event, please sign and return the following statement of consent and release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may result from any personal actions taken by your youth. Revised 08/07 Parent / Guardian Consent and Emergency Medical Release Form 1 I hereby consent to participation by my youth _______________ in the event described above. I understand that this event will take place away from the parish grounds and that my youth will be under the supervision of the designated supervisor on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation. In consideration for 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 Pensacola-Tallahassee and _Christ Our Redeemer Parish, its volunteers, and other persons acting on their behalf. Neither the Diocese of Pensacola-Tallahassee, ___Christ Our Redeemer Parish, its agents, or volunteers, shall be held financially responsible for any injury, illness or death incurred as a direct or indirect result of this activity. We the undersigned have read this release and understand all its terms and execute it voluntarily and with full knowledge of its significance. EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I/we hereby authorize the Diocese of Pensacola-Tallahassee, and __Christ Our Redeemer_________ Parish, through its authorized representatives, to transport my child to a hospital or other doctor’s office or medical facility for emergency medical attention. I/We additionally authorize such representatives of the Diocese and/or School to obtain and give consent to whatever medical treatment the representative deems necessary, including the administering of anesthetic and surgery, and do hereby release the Diocese and _Christ Our Redeemer__Parish, and their authorized representatives from any and all claims which may arise from the above-referenced obtaining and consenting to medical treatment. I/We wish to be advised, if possible, prior to the providing of any non-emergency medical treatment by any physician or hospital. If I/we are unable to be reached, please contact the following: Emergency contact and relation to participant_______________________________________ Address and Phone Number _______________________________________________ Finally, I/we hereby give permission for the Diocese of Pensacola-Tallahassee and any of its affiliated organizations, including, but not limited to The Florida Catholic, to use the name of my child and/or his/her photograph for promotional, news, or public relations purposes in print and/or electronic media. _______________________________________________ Print Parent/Guardian Name ________________________________________________________ ___________________ Signature of Parent/Guardian Date This form must be with the head chaperone at all diocesan and parish events Revised 08/07 Parent / Guardian Consent and Emergency Medical Release Form 2
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