Microsoft word - ola highschool

Franciscan Renewal Center
Medical Release/General Permission/Photo Slip: High School Youth Ministry Program Name _____________________________________________________________ Phone ____________________ Student’s Email__________________________________________________________________________________ Address _______________________________________________________________________________________ City_________________________State___________Zip____________School_______________________________ Parish __________________________ Birth date _________________ Grade______ Gender____TShirt Size _____ Parent/Guardian’s Email __________________________________________________________________________ Parent/Guardian's Name_________________________________________ Phone___________________ Parent/Guardian's Name_________________________________________ Phone___________________ EMERGENCY CONTACT IN THE EVENT THE PARENT(S) CANNOT BE NOTIFIED: Name ____________________________________________________________ Phone ________________________________ Doctor's Name _____________________________________________ Dr.'s Phone _________________________ Insurance Company _________________________________________ Policy # ____________________________ ARE THERE ANY KNOWN ALLERGIES TO FOOD OR MEDICATIONS THAT THOSE WHO WORK WITH YOUR YOUNG PERSON ON THIS EVENT SHOULD BE AWARE OF? Yes No If Yes, explain: __________________________________________________________________________________ Any medications currently taking: ___________________________________________________________________ List medications your child has permission to self-medicate: ______________________________________________ I hereby authorize a responsible adult to dispense to my child, if needed, only the following that are initialed by a parent of guardian. (Please initial all that apply). I request that my son/daughter participate in the youth ministry program, Sponsored by the Franciscan Renewal Center. These activities will take place on Sundays throughout the school year. I understand that reasonable precautions will be taken to safeguard the health and well being of my son/daughter and that I will be notified as soon as possible in the event of an emergency. In case of any sickness or accident, I authorize and consent to any x-ray, exam, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care to be rendered to my son/daughter under the general or specific supervision and on the advice of any physician, dentist, or surgeon licensed to practice. I further understand and agree to be responsible for any such medical, dental or hospital expenses incurred. Further, in the event of sickness, injury or accident, I will not hold The Church of Our Lady of the Angels, The Franciscan Renewal Center, the Franciscan Province of St. Barbara, the Diocese of Phoenix, or any youth leader responsible. I further agree to arrange for or provide transportation to and from the youth program including any event in which my child must leave the event prior to its conclusion due to sickness, injury, accident, or my child’s actions or behavior. Date _______________________ Parent/Guardian ____________________________________________________ I hereby grant my consent to use and release to: the Franciscan Renewal Center & The Catholic Diocese of Phoenix the use of my name and or my likeness or my teen’s name or likeness, whether in still, motion pictures, audio or video tape, photograph and/or other reproduction of me or my child, including voice and features, with or without names, of any promotional purposes involving the diocese or parish or program, news feature stories in The Catholic Sun or other media or other purpose whatsoever, except for the endorsement of any commercial products. I further agree that the Catholic Diocese of Phoenix may use or cause to be used, these items for any and all broadcasts, publications or reproductions, without limitation or reservation of any fee. Date _______________________ Parent/Guardian ____________________________________________________ (When traveling out of state, minors under 18 must have form notarized.)

Source: http://www.casayouth.org/CasaYouth/High_School_files/OLA%20HighSchool.pdf