PSR Emergency Information

PSR Emergency Information
Special Needs: Please list child(ren) and describe any health or learning needs. We are grateful for any information that will help the catechist assist you in the faith formation of your child
Please list the names of two contacts available during PSR time that you authorize to care for or direct care for your child(ren) in the event you cannot be contacted.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Child*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Child*
In case of accident or serious illness, I request the Parish School of Religion contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated below and to follow the instructions given. If it is impossible to contact this physician, I further authorize the school to make necessary arrangements to care for the child.
Physician Name*

First NameLast Name
Office Phone Number*
Please enter a valid phone number.
Emergency Phone Number*
Please enter a valid phone number.
Preferred Hospital*
Hospital Phone Number
Please enter a valid phone number.
Signature of Parent or Guardian

Clear
PERSONS AUTHORIZED TO TAKE CHILD(REN) FROMTHE PARISH SCHOOL OF RELIGION PROGRAM
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Should be Empty: