ࡱ > 6 8 5 bjbj 0$ 0 0 0 0 L 0 . ` ` ` ` ` ; ; ; Y [ [ [ [ [ [ $ ! ; ; ; ; ; ` ` ; ` ` e ; Y ` P¨ Q X Q 0 " " " ; ; ; ; ; ; ; ; ; ; ; ; ; ; " ; ; ; ; ; ; ; ; ; : 2019 - 2020 Student Medical Record Form Student Name ________________________________________________ Birth Date: ________________ Medical Information: Medical Condition(s) : _______________________________________________________________________________ Prescriptions: _______________________________________________________________________________________ Allergies: __________________________________________________________________________________________ Name of Family Physician ________________________________________ Phone: ______________________________ Insurance Information: Insurance Name: ___________________________ Policy No. __________________ Certificate No: _______________ Parent Cell Phone(s): Mom __________________________ Dad _________________________________________ EMERGENCY CONTACT INFORMATION: In the event of an emergency/accident/illness, parents will be contacted first but if unavailable, the people listed below have the permission to be contacted and pick up my child from Faith Formation. Name of first emergency contact: __________________________________________________________________________________ Relationship: ______________________________________ Phone: ______________________________________________ Name of second emergency contact: ________________________________________________________________________________ Relationship: ______________________________________ Phone: ______________________________________________ Name of third emergency contact: _________________________________________________________________________________ Relationship: ______________________________________ Phone: ______________________________________________ NAME ANYONE WHO IS RESTRAINED FROM PICKING UP YOUR CHILD: _________________________________ Liability Release I/We, the parent/parents and or legal guardian(s) of the above named child, hereby request permission for my son/daughter to participate in any and all of the activities of the Roman Catholic Diocese of Owensboro and the Paducah Catholic Community Faith Formation. I/We do hereby further generally, fully, completely and absolutely hold harmless the Diocese of Owensboro and the Paducah Catholic Community Faith Formation, including but not limited to, all staff, board members, catechists and aides, leaders, volunteer drivers and chaperones from any and all liability of any kind or nature whatsoever. In case of injury to my/our child, I/we hereby waive all claims against the parties set forth above, and further agree to fully indemnify and hold said parties harmless from any liability whatsoever. I/We likewise release from responsibility any person transporting my child to or from the activities. I/We understand the possibility of unforeseen hazards and know inherent possibility of risk. I/We believe that the subject of this release is physically and mentally capable of taking reasonable precautions to protect his/her own safety and has the maturity and judgment not to put himself/herself or others in dangerous situations. Consent for Emergency Care I/We, the undersigned parent/(s)/guardian 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 childs 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 school to secure necessary medical attention. I/we further authorize any qualified physician, dentist, or hospital to render such aid/treatment that may be necessary and understand that I/we assume responsibility for the cost of any such treatment. I/we authorize the release of pertinent medical information to supervisory personnel. I/we understand that, depending upon the seriousness of the situation, my child may be transported to the nearest hospital. X_____________________________________________________ Date: __________________________________ Signature of Parent or Guardian X______________________________________________________ Date: _______________________________ Witness ( p q | } u E F ] w x ƽ}rjrbZbrbrbR}bZh&