St.
William’s Parish
Name: ________________________________ Date of Birth_______
Address: ________________________City: ____________State:___
Tele.:__________________________ Male____ Female____
INSURANCE INFORMATION
Physician or Clinic: ______________________Tele.:_____________
Specific medical condition/s or other necessary health information: ________________________________________________________
________________________________________________________
As the parent or guardian of _______________ I give permission for my child to participate in the activity stated above. My child has my permission to be transported to and from this activity. I understand that neither St. William’s Parish or any of its agents are responsible for any injury sustained by my child. I accept responsibility for any medical expenses as a result of any such injury sustained.
Signature Parent/Guardian: _____________________ Date:______
_______________________________________________________
MEDICAL RELEASE
As the parent or guardian of _________________, I do herewith authorize the treatment by a qualified and licensed medical doctor of my child in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.
Signature Parent/Guardian: ______________________ Date:______
Home Work Cell
Tele:______________ Tele: ______________ Tele: _____________
Another person to contact in case of emergency:
Name: ________________ Relationship: ________Tele:_________
Please be sure to place payment and permission in an envelope addressed to Fran Spinale and leave at the Rectory.