Diocesan Emergency and Medical Release Form

Child Name(Required)

First Last

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email(Required)

Parent/Guardian Phone Number(Required)

Parish(Required)

In the event of an emergency, if we are unable to reach you at the above number, please enter an Emergency Contact below.

Emergency Contact Name(Required)

First Last

Emergency Contact Phone Number(Required)

Please list any known allergies or conditions (or type "none")(Required)

Physician's Name(Required)

Family Health Plan Carrier(Required)

Policy Number(Required)

Telephone Number(Required)

Medications currently taken (prescription and non-prescription) and include dosage (or type "none"):(Required)

Parent/Guardian Signature(Required)