St. Joseph DeWitt IA Totus Tuus 2025

Health and Medical Information Form

Name*

First NameLast Name

Date*

Date

Birth date*

Date

Parent or Guardian*

Grade for '25-'26*

Address*

Address

Street Address Line 2

City

Zip

Home Phone*

Email address*

example@example.com

Work Phone

In case of emergency, please notify:

Emergency Contact 1*

Relationship*

Phone*

Emergency Contact 2

Relationship

Phone

Insurance Company*

Policyholder*

Policy number*

Please circle illnesses, allergies or medication reactions you have experienced and give dates

Please select illnesses, allergies or medication reactions you have experienced

Please select all up-to-date immunizations

DPT Series BoosterTetanus BoosterPolio OPV BoosterTB Test

Operations or serious injuries

Chronic or recurring illness

Any activity restrictions

Medications List directions

My child may be given if needed (mark approved)

AspirinTylenolIbuprofen

Dietary Restrictions

I submit that this health history is accurate and correct as far as I know, and the person described has permission to engage in all planned activities, except as noted by me, or an examining physician In the event of an emergency, I hereby give permission to the physician selected by the youth director to secure proper and adequate treatment including hospitalization, injection, anesthesia or surgery, for myself, if majority age, or the child listed, if a minor. I accept responsibility for all medical/surgical treatment charges, which may be incurred. I hereby release Saint Joseph Parish, DeWitt, Iowa, Diocese of Davenport, Davenport, Iowa, and all adult supervision from any and all claims arising out of or from any accident or other occurrence causing injury to any person or property during this activity. If my child's photograph is taken it may be used for promotional

Signature of Parent or Guardian*

Date*

Date