2020 Religious Education Registration

Medical Information - Student One
Does your son/ daughter have any medical problems, allergies or physical limitations that we should know about ?

Yes No
If yes, please explain
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
Hospital Preference
In case of a medical emergency, I give Bernard of Clairvaux and St. Stanislaus Kostka authorization to take my child for emergency medical care.

Yes No
Add another child? *

Yes No

Medical Information - Student Two
Does your son/ daughter have any medical problems, allergies or physical limitations that we should know about ?

Yes No
If yes, please explain
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
Hospital Preference
In case of a medical emergency, I give Bernard of Clairvaux and St. Stanislaus Kostka authorization to take my child for emergency medical care.

Yes No
Add another child? *

Yes No

Medical Information - Student Three
Does your son/ daughter have any medical problems, allergies or physical limitations that we should know about ?

Yes No
If yes, please explain
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
Hospital Preference
In case of a medical emergency, I give Bernard of Clairvaux and St. Stanislaus Kostka authorization to take my child for emergency medical care.

Yes No
Add another child? *

Yes No

Medical Information - Student Four
Does your son/ daughter have any medical problems, allergies or physical limitations that we should know about ?

Yes No
If yes, please explain
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
Hospital Preference
In case of a medical emergency, I give Bernard of Clairvaux and St. Stanislaus Kostka authorization to take my child for emergency medical care.

Yes No
Add another child? *

Yes No

Medical Information - Student Five
Does your son/ daughter have any medical problems, allergies or physical limitations that we should know about ?

Yes No
If yes, please explain
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
Hospital Preference
In case of a medical emergency, I give Bernard of Clairvaux and St. Stanislaus Kostka authorization to take my child for emergency medical care.

Yes No
Add another child? *

Yes No

Medical Information - Student Six
Does your son/ daughter have any medical problems, allergies or physical limitations that we should know about ?

Yes No
If yes, please explain
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
Hospital Preference
In case of a medical emergency, I give Bernard of Clairvaux and St. Stanislaus Kostka authorization to take my child for emergency medical care.

Yes No
Add another child? *

Yes No

Medical Information - Student Seven
Does your son/ daughter have any medical problems, allergies or physical limitations that we should know about ?

Yes No
If yes, please explain
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
Hospital Preference
In case of a medical emergency, I give Bernard of Clairvaux and St. Stanislaus Kostka authorization to take my child for emergency medical care.

Yes No
Add another child?

Yes No

Medical Information - Student Eight
Does your son/ daughter have any medical problems, allergies or physical limitations that we should know about ?

Yes No
If yes, please explain
Doctor's Name
Doctor's Phone Number
Doctor's Phone Number
Hospital Preference
In case of a medical emergency, I give Bernard of Clairvaux and St. Stanislaus Kostka authorization to take my child for emergency medical care.

Yes No

Emergency Contact Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Relationship to child
Home Phone Number
Home Phone Number
Cell Phone Number
Cell Phone Number
Should be Empty:

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