PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
Medical Matters
MEDICAL
MATTERS: I hereby warrant that 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 that are applicable.)
Participant’s name:
_____________________________________________________
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. In the event
of an emergency,
if you are unable to reach me at the above numbers, contact:
Name & relationship:
_________________________________________________
Phone: ____________ Family doctor: _______________ Phone:
_______________
Family Health Plan Carrier: _______________________ Policy
#: ______________
Signature: ____________________________________ Date:
________________
Other Medical Treatment: In the event it comes to the
attention of the parish, its officers, directors and agents, and the Catholic
Diocese of Green Bay, coaches, chaperons, or representatives associated with
the activity that my child becomes ill with symptoms such as headache,
vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone
charges reversed to myself).
Signature: ______________________________________ Date:
_____________
Medications: My child is taking medication at present. My child
will bring all such
medications necessary, and such medications will be well labeled. Names of
medications and concise directions for seeing that the child takes such
medications, including dosage and frequency of dosage, are as follows:
__________________________________________________________________
_________________________________________________________________
Signature: ______________________________________ Date:
_____________
No 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.
Signature: ______________________________________ Date:
_____________
I hereby grant permission for non-prescription medication
(such as aspirin, throat lozenges, cough syrup) to be given to my child, if
deemed appropriate.
Signature: ______________________________________ Date:
_____________
Specific Medical Information: The parish will take
reasonable care to see that the following information will be held in
confidence. Allergic reactions (medications, foods, plants, insects, etc.):
_____________________________________________________________________________________________
Immunizations: Date of last tetanus/diphtheria immunization:____________________________
Does child have a medically prescribed diet?
________________________________________
Are there any physical limitations?
________________________________________________
Has child recently been exposed to contagious disease or
conditions, such as mumps,
measles, chickenpox, etc.? If so, date and disease or condition:
____________________________________________________________________________
You should be aware of these special medical conditions of
my child:
____________________________________________________________________________
____________________________________________________________________________