Child’s Name___________________________________________ Date of Birth ______________________

Parent/Guardian Name _____________________________________________________________________

Home Address __________________________________________Home Phone _______________________

Name of  Diocesan Entity: ___________________________________________________________________

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 in accordance with your wishes.)

EMERGENCY MEDICAL TREATMENT:  In the event of an emergency, I hereby give permission to the above named
Diocesan entity’s employees, volunteers, or representatives to seek medical treatment for my child above names.

In the event that I cannot be reached in an emergency, I hereby give permission to the physical selected by the above
named Diocesan entity’s representatives or volunteers to hospitalize, secure proper treatment for, and to order injection
and/or anesthesia and/or surgery for my child above named.

In the event of an emergency, if you are unable to reach me at the above number, contact:

Name and Relationship ______________________________________      Phone _________________________

Family Doctor _____________________________________________      Phone _________________________

Family Health Plan Carrier: __________________________________      Policy Number ___________________

I make the following exception __________________________________________________________________

Medication __________________________Dosage ___________________Doctor ________________________

Medical Problem or Condition (allergies, diabetes) __________________________________________________

Condition ______________________________________________Symptoms____________________________

Physical Disabilities __________________________________________________________________________

_________________________________________________________          ____________________________
                             Signature of Parent/Guardian                                                                     Date

OTHER MEDICAL TREATMENT:  In the event it comes to the attention of the above named Diocesan entity’s volunteers
or representatives that my child becomes ill with symptoms such as headache, vomiting, sore throat, fever, or diarrhea,
I hereby give permission for over-the-counter medication to be administered to my child according to directions.

_________________________________________________________          ____________________________
                             Signature of Parent/Guardian                                                                     Date
 
HR 2001