Form A Emergency Medical Release & Health Information for Minors

  • Medical History


  • do hereby request and give permission for the provision of necessary medical treatment for the above-named child. I/we understand that supervisory personnel will immediately seek to reach the above-named child’s contact(s) in case of a medical emergency. If any injury/incident does occur during this event that requires transportation to a hospital or doctor, I/we give permission for a representative of the parish/school/etc. to secure necessary medical attention. I/we further authorize any duly qualified physician, dentist, or hospital to render such aid or treatment that may be necessary and understand that I/we assumeresponsibility for the cost of any such treatment. I/we authorize the release of pertinent medical information to supervisory personnel.* Please understand that, depending upon the seriousness of the situation, your child may be transported to the nearest hospital.

    This Permission Form/Liability Release is intended to cover all diocesan-, deanery-, parish-, and Catholic school-sponsored activities for anyone under the age of eighteen (18). Catholic schools and/or programs have the right to require parent/guardian to give permission for students/participants eighteen (18) years of age or older.
  • IF THERE ARE ANY CHANGES IN THE INFORMATION ON THIS FORM, IT IS YOUR RESPONSIBILITY TO NOTIFY THE APPROPRIATE LEADER AND GET THE FORM UPDATED. (e.g. insurance policy changes, changes in medical condition or medicines, court orders, etc.)

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