2025 JCDA Medical Release

Junior Catholic Daughters of the Americas
MEDICAL RELEASE
COURT: St. Faustina and 2478
To whom it may concern: (Daughters Name)* has my permission to attend all functions planned and chaperoned by the leaders of JCDA Court (Court Number). I understand that I will be notified, in advance, of any activities that take place away from (St.Monica) Parish. I permit Hospital Care Physicians and any other physician she may wish to delegate, to render any medical/ surgical treatment for the above named patient in my absence.
Signature of Parent or Guardian
Type Name
Date

MonthDayYear
Date
EMERGENCY CONTACT
Name
Relationship
Telephone Number
Format: (000) 000-0000.
ALTERNATE EMERGENCY CONTACT
Name
Relationship
Telephone Number
Format: (000) 000-0000.
MEMBER’S MEDICAL HISTORY
Allergies, if any
Date of last Tetanus Immunization

MonthDayYear
Date
Medications
Other
Health Insurance Carrier
Policy Number
Approved by the National Board 01/19
Should be Empty:

Junior Catholic Daughters of the Americas