______________________________________________________________________________

Name of Program                                                                                   Date of Program

_____________________________________________________________________________________

Name of Student                                     Social Security Number                        Age                  Sex

_____________________________________________________________________________________

Address                                                City                        State     Zip            Phone

_____________________________________________________________________________________

School                                                                          Grade                           Birth Date    

PERMISSION

I/we, the parents or guardians of the above-mentioned child, for myself/ourselves and for my/our child, give permission for my/our child to participate in the above-mentioned St. Richards Youth Ministry program, on the above written dates.

MEDICAL AUTHORIZATION

In the event of any injury or illness to my/our child during his/her participation in the program, I/we hereby give my/our permission for the necessary medical treatment to be given to my/our child.  I/we, for myself/ourselves, for my/our child our respective heirs, and my/our respective legal representatives, do hereby indemnify and hold harmless any representative of St. Richard Church and/or the Roman Catholic Diocese of Pittsburgh from any and all claims, demands, and causes of action of whatever kind of nature for their actions taken pursuant to this authority. 

I/we agree that in case of injury to my/our child, I/we will apply my/our hospitalization and/or accident insurance toward payment of the expenses incurred and will not look to St. Richard Church and/or the Roman Catholic Diocese of Pittsburgh for the payment of any medical costs or injury related costs.

_____________________________________________________________________________________

Parent/Guardian Signature                                                          Parent/Guardian Phone Number

_____________________________________________________________________________________

Insurance Company                                                                      Policy Number

_____________________________________________________________________________________

Name and phone number of person if Parent/Guardian is not available

CONSENT TO TREAT

I/We the undersigned parent(s)/guardian of _______________________________________, a minor, do hereby authorize treatment of my/our child by a licensed medical physician in case of any accident of illness that may so arise, or any hospitalization necessary.

______________________________________________________________________________

Father/Legal Guardian                                   OR                  Mother/Legal Guardian

Date:____________________  This consent will remain effective until 48 hours after to event.

MEDICAL MATTERS:  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.  Of the following statements pertaining to medical matters, SIGN ONLY THOSE IN ACCORDANCE WITH YOUR WISHES.

1)      Medications:  My child is taking medication at present.  My child will bring all such medications necessary, and such medications will be well labeled.  My child will administer his/her own medication.

______________________________________________________________________________

Signature:_____________________________________________ Date:____________________

2)      I hereby grant permission for nonprescription medication (such as Tylenol, throat lozenges, cough syrup, etc.) to be given to my child if deemed advisable.

Signature:_____________________________________________ Date:____________________

3)      No medicating of any type whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required.

Signature:_____________________________________________ Date:____________________

Any known allergies?:____________________________________________________________

Any physical limitations?:_________________________________________________________

Any medically prescribed dietary needs?:_____________________________________________

Is the child a vegetarian?:  YES             NO

Is the child subject to chronic homesickness, emotional reactions to new situations, or fainting?:

YES             NO

If yes, explain: __________________________________________________________________