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Parent/Guardian Consent Form and Liability Waiver - Medical Matters

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- Participant's Name: REQUIRED Please fill out this field. Please enter valid data.
- 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.
- Signature REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
- 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.
  
  I Agree Please select this field.
  
  In the event of an emergency, if you are unable to reach me, contact:
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to the student REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Family Doctor REQUIRED Please fill out this field. Please enter valid data.
  
  Family Health Plan Carrier REQUIRED Please fill out this field. Please enter valid data.
  
  Policy Number Please enter an integer (number).
  
  Other Medical Treatment:
  In the event it comes to the attention of the parish/school, its officers, directors and agents, and/or The Diocese of Sioux City, chaperones, 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.
  
  I Agree Please select this field.
  
  Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Today's Date REQUIRED Please fill out this field. Please enter a date.
- MEDICATIONS
  
  My child is currently taking medications. I understand my child will bring all such medications as necessary, and medications will be clearly labeled. REQUIRED Yes No Please fill out this field.
  
  List of Medications, dosages and frequency, if applicable: Maximum 200 characters Please enter valid data.
  
  Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a 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. REQUIRED Yes No Please fill out this field.
  
  I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate. REQUIRED Yes No Please fill out this field.
  
  Signature REQUIRED Please fill out this field. Please enter valid data.
  
  Date REQUIRED Please fill out this field. Please enter a date.
- SPECIFIC MEDICAL INFORMATION
  
  : The parish/school will take reasonable care to see that the following information will be held in confidence.
  
  Allergic reactions (medications, foods, plants, insects, etc.) Please enter valid data.
  
  Immunizations: Date of last tetanus/diphtheria immunization: Please enter valid data.
  
  Any physical limitations? REQUIRED Please fill out this field. Please enter valid data.
  
  Does child have a medically prescribed diet? REQUIRED Please fill out this field. Please enter valid data.
  
  Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting? REQUIRED Please fill out this field. Please enter valid data.
  
  Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chicken pox, etc.? If so, list date and disease or condition: REQUIRED Please fill out this field.
  
  You should be aware of these special medical conditions of my child: Please enter valid data.
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saint donatus (formerly pilgrim cluster)

Catholic Parishes of Alton/Granville/Hospers, IA

Parent/Guardian Consent Form and Liability Waiver - Medical Matters