Youth medical release 08-09.indd

Family Last Name____________________________ Today’s Date____________ MARY IMMACULATE PERMISSION SLIP/EMERGENCY RELEASE FORM
Youth’s Name:___________________________________ Will begin the ________ grade in August of 200_________. DOB_________________ Male__Female__ Age__________ T-Shirt Size: S___M___L___XL___XXL___ Address_____________________________________ City________________ Sate_____ Zip________________ School_________________Parent (s)/Guardian Name________________________________________________ Home Phone__________________ Work Phone____________________ Cell Phone_____________________ Physician’s Name____________________________________________ Phone________________________ Insurance Company Name__________________________________ Member ID#_________________________ Policy # _________________________________ Group #____________________ Phone #__________________ Pertinent Medical Information (including drug allergies, chronic conditions, current medications, other)___________________________________________________________________________________ IN CASE OF EMERGENCY, PLEASE CONTACT ONE OF THE FOLLOWING PERSONS:
Emergency Contact Person:_______________________________________Phone No.____________________________ Emergency Contact Person:_______________________________________Phone No.____________________________ Emergency Contact Person:_______________________________________Phone No.____________________________ PERMISSION TO TRAVEL AND PARTICIPATE / LIABILITY RELEASE:
I/We, ________________________________the parent (s)/guardians of ___________________________, a minor, do hereby give him/her permission to travel with the youth group of Mary Immaculate Catholic Church and to participate in all youth activities and functions. We understand that our child may be traveling via public or private transportation (for example: car, bus, boat, van, plane). We hereby recognize the inherent risk associated with the various youth activities and forms of travel, and agree to save and hold harmless Mary Immaculate Catholic Church, the Roman Catholic Diocese of Dallas, and their employees, volunteers, and agents from any liability or expense that may arise from my child’s participation in youth events and any travel related incidents going to and from such event. *Signature of Parent/Guardian_______________________________________ Date________________ *Signature of Parent/Guardian_______________________________________ Date________________ PERMISSION TO DISPENSE OVER THE COUNTER MEDS AND FIRST AID:
I/We, _____________________________the parent (s)/guardians of __________________________a minor, do hereby give my son/daughter permission to take the following “over the counter” medications as needed for minor aches and painsunder the supervision of church personnel. Circle any and all that apply
--Immodium --Antacid --Dramamine --Benadryl --Sudafed --Acetaminophen (Tylenol) --Ibuprofen --Advil --Triaminic Cough Syrup --Midol --Other_________________________________________________________________________________ *Parent/Guardian Signature__________________________________________ Date_______________ *Parent/Guardian Signature_____________________________________ Date_______________ (PLEASE COMPLETE THE BACK)
AUTHORIZATION OF CONSENT TO TREAT MINOR:
I/We, ______________________________the parent (s)/guardians of ___________________________, a minor, do hereby authorize Mary Immaculate Catholic Church, youth ministry leaders, servants, employees, officers and adult volunteers as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital. It is understood that this authorization is given in advance of any specific treatment or diagnosis, but is given to provide authority and power of treatment, or hospital care which the aforementioned physician in the exercise of best judgment may deem advisable. This authorization is given pursuant to the provisions of Chapter 32 of the Texas Family Code. This authorization shall remain effective for up to one year from the date of completion of this form, unless sooner revoked in writing delivered to said agent(s). _________________________(Parent’s name) shall indemnify, hold free and harmless, assume liability for, and defend Mary Immaculate Catholic Church, its agents, servants, employees, officers, and directors from any and all costs and expenses including but not limited to, medical fees, attorney’s fees, discovery costs, court costs, and all other sums associated with any claim or action founded thereon, including those arising or alleged to have arisen out of treatment of aforementioned minor. We also release Mary Immaculate Catholic Church, the Dallas Catholic Diocese, and any agents of the church of any liability incurred due to aforementioned minor’s use of real or personal property belonging to Mary Immaculate Catholic Church, its agents, employees, or volunteers. Parent/Legal Guardian’s Signature_______________________________________ Date______________ I (we) grant Mary Immaculate Church all right, title, and interest in any and all photographic images and video or audio recordings made by Mary Immaculate Church or its agents during the aforementioned minor’s activities with Mary Immaculate Church or its agents, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. We allow all photographic and video images to be used by Mary Immaculate Church or its agents it what ever ways they deem fit. Parent/Legal Guardian’s Signature_______________________________________ Date______________

Source: http://maryimmaculatechurch.org/home/2706/3105/docs/Youth%20Medical%20Release_1-Eng.pdf?sec_id=3105