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This form is to be used for all young people through age 18. FORM A
OFFICE OF YOUTH MINISTRY AND YOUNG ADULT MINISTRY DIOCESE OF VICTORIA IN TEXAS PERMISSION FORM/MEDICAL RELEASE Name:_____________________________________________________Sex:____________ Grade:_________ Address:____________________________________________City:__________________________________ Phone: ___________________ Work:____________________Cell:__________________________________ Age: ___________Birthdate:___________________________Parish: Holy Cross PARENT/LEGAL GUARDIAN’S NAME:___________________________________________________ Address (if different than above):____________________________________________________________ Phone (if different than above):_____________________________________________________________ I hereby consent to participation by my son/daughter,____________________________, in all youth events sponsored by the LIFE TEEN program of Holy Cross Parish, and of the Diocese of Victoria from September 1, 2005 through August 31, 2006. I understand that the activity will take place at the parish or other locations throughout the Diocese and that my son/daughter will be under the supervision of diocesan and/or parish personnel. As parent or legal guardian I agree to defend, indemnify and hold harmless Holy Cross Catholic Church and the Diocese of Victoria, its clergy, officers, agents, employees and volunteers from any claims, costs or expenses for property damages, personal injuries or other damages arising out of my son/daughter’s participation in the above mentioned activity. I grant permission for non-prescriptive medication (e.g. Tylenol, throat lozenges, cough syrup, pepto-bismol, etc.) and routine nonsurgical medical care to be given to my son/daughter if deemed advisable by the supervising diocesan personnel. In case of an emergency, I also grant permission to transport my child to the nearest hospital for emergency medical or surgical treatment and for an authorized adult sponsor to sign for treatment if I cannot be located. I grant permission for my child to have his/her picture taken or video taken during church related activities. The picture or video may be used for promotional purposes for our church. Date: _______________ Parent’s Signature:__________________________________ Family Physician:_______________________________________________Phone:_________________ Address:___________________________________________________________________________ My son/daughter is allergic to:___________________________________________________________ My son/daughter takes the following medication:_____________________________________________ This medication is for:_________________________________________________________________ My son/daughter is allergic to:___________________________________________________________ Last immunization/booster for Diphtheria/Tetanus:____________________________________________ Any specific medical problems: __________________________Any physical limitations:______________ In an emergency, if unable to reach parent/guardian, please contact: Name: _________________________________Wk Ph:_______________Hm Ph:________________ Name:__________________________________Wk Ph:_______________Hm Ph:________________ Name of Insurance Company:_____________________________________Phone:________________ Address:__________________________________________________________________________ Name of Insured:____________________________________________________________________ Policy #:___________________________________________________________________________ Group or Plan #:_____________________________________________________________________ |