I give my permission for my son/daughter ___________________________________ to receive emergency medical treatment, if ever necessary, when participating in a Saint Bridget Youth Ministry activity for the 2007-2008 schedule of events.

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. In the event of an emergency and I cannot be reached, I hereby give permission to transport my child to a hospital or medical facility and to seek medical attention. I give permission for the administration of non-prescription medication – aspirin, throat lozenges or cough syrup – if deemed appropriate and if the situation is not life-threatening.

Emergency contact person: _________________________ Relationship: ______________ Phone: ______________

Doctor Name: ____________________________ Phone: ____________________

Insurance: Company: ___________________ Employer: _____________________ Group #: ______________

Subscriber Name: _________________________ Subscriber #: ___________________________

Date of last tetanus shot: ____________________

Please list any allergies: (medication, food, plants, insects) _____________________________________________________________________________________________

_____________________________________________________________________________________________

Please list any surgeries or recent serious health problems that we may need to be aware of: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Please list any medications your youth is taking and/or health ailments that pertain to your youth that we may need to be aware of (including daily vitamin): _____________________________________________________________________________________________

_____________________________________________________________________________________________ 

I relieve St. Bridget Church of all responsibility and consequences that may arise as a result of this treatment. I will not hold St. Bridget Church liable in the event of injury. Further, I agree to accept full financial responsibility for any medical treatment resulting from injury.

This information will be held on file for the 2007-2008 year. If your teenager does not submit this form he/she will not be able to attend special events.  

Parent/Guardian Signature:___________________________ Print Name:_______________________ Date:_______