ARCHDIOCESE
OF
Medical
Information & Emergency Consent Form
Participant’s
Name ____________________________________________________________________
Address
_____________________________________________________________________________
City
_____________________________________ Zip _____________ Phone
___________________
Parent
/ Legal Guardian
________________________________________________________________
Address
____________________________________________________________________________
Employer
___________________________________________________________________________
Home
Phone ______________________ Work Phone ______________________
MEDICAL
INFORMATION:
Family
Physician: _______________________________________ Phone
_______________________
Group
/ Address _____________________________________________________________________
Hospital
of preference: ________________________________________________________________
Insurance
Info: Subscriber: _____________________________ Group #: _______________________
Policy
#: ________________________________ Company: __________________________________
Medical
problems: ___________________________________________________________________
Allergies:
__________________________________________________________________________
In
the event of an injury or illness I/we grant permission to any and all health
care providers designated by
______________________________
to provide my/our child
_________________________________
any and all necessary medical care related to
the injury or illness. I/we further understand I/we will be
contacted as soon as practical as to
the medical emergency and be provided with all necessary information
related to the medical emergency.
Signed
this __________ day of __________________ 20_____
_____________________________________
_________________________________________
Parent
/ Legal Guardian Parent / Legal Guardian
Form 6145.2(a), 5141.1 Archdiocese
of
Form revised:
Form
6145.2A