St. Francis of Assisi Permission Form

ST. FRANCIS OF ASSISI YOUTH MINISTRY PERMISSION/MEDICAL WAIVER
PERMISSION INFORMATION
Name of Youth

First Name Last Name
I,

First Name Last Name
(parent/guardian) request that my child, named above, be allowed to participate in Youth Hangouts. I further give my permission for my child to ride in any vehicle designated by the adult in whose care my child has been entrusted while participating in the above activities.

I give my permission to use my child’s name, photograph and/or videotaped image in print/video on the St. Francis of Assisi Youth Ministry website, Facebook Pages and Instagram
Yes No
In consideration of permitting my child to attend and/or participate, I do hereby, for myself, and my child waive and release any and all claims that I might have against St. Francis of Assisi Parish, the Archdiocese of Louisville, the Director of Youth Ministry and any chaperones or designated drivers of a van, bus, car or vehicle, for any and all injuries or losses suffered by said child while engaged in the youth ministry activities.
Signature of Parent/Guardian

Clear
Date

Month Day Year
Date
MEDICAL INFORMATION
Youth Name
Date of Birth

Month Day Year
Date
Gender

Male Female
School Graduation Year
Youth Cell Phone
Youth E Mail
example@example.com
Parent/Guardian Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent Email(s)
example@example.com
Mom Cell #
Dad Cell #
Home/Work #
Food Allergies:
Medicine Allergies:
Other Allergies:
Current Medications:
Family Physician or Clinic
Physician Phone #:
Insurance Company
Policy #
Group #
I give permission to the Youth Minister or other adult chaperone to administer Tylenol or other affiliates to my child
No Yes
EMERGENCY CONTACTS
1. Name
Phone
Relationship to Child
2. Name
Phone Number
Relationship to Child
Signature

Clear
In case of any medical emergency, I understand that every effort will be made to contact the parents or guardians of the child participating in the Youth Ministry Programming of the parish. In the event that I cannot be reached, I hereby give permission to the physician selected by the Youth Minister to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named herein.
Date

Month Day Year
Date
Should be Empty:

PERMISSION INFORMATION

MEDICAL INFORMATION

EMERGENCY CONTACTS