Parental/legal Guardian Consent Form And Liability Waiver Page 2
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Student’s name _____________________
Family doctor ________________________________ Phone # _______________________
Family Health Plan Carrier ______________________
Policy # ___________________
_____________________________
___________________________
_______
(Signature)
(Relationship
(Date)
)
(Of the following statements pertaining to medical matters, sign only those that are applicable
Other Medical Treatment:
In the event it comes to the attention of the parish, its officers, directors
and agents, and the Catholic Diocese of Fort Wayne-South Bend, chaperone, or representatives associated
with the activity that my child becomes ill with symptoms such as headache. Vomiting, sore throat, fever,
diarrhea, I want to be called collect (with phone charges reversed to myself).
Signature ______________________________
Date _______________________
Medications: My child is taking medication at present. My child will bring all such medications necessary, and
such medications will be well-labeled. Names of medications and concise directions for seeing that the child
takes such medications, including dosage and frequency of dosage, are as follows:
______________________________ _________________________________________
_______________________________ _______________________________________________.
Signature ______________________________
Date __________________________
NO medication of any type, whether prescription or non-prescription, may be administered to my child unless
-threatening and emergency treatment is required.
the situation is life
Signature ______________________________
Date __________________________
I hereby grant permission for non-prescription medication (such as non-aspirin products, i.e. acetaminophen or
.
ibuprofen, throat lozenges, cough syrup) to be given to my child, if deemed appropriate
Signature _______________________________
Date ____________________________
Specific Medical Information:
The parish will take reasonable care to see that the following
information will be held in confidence.
Allergic reactions (medications, food, plants, insects, etc.) _______________________________
Immunizations: Date of last tetanus/diphtheria immunization: _____________________________
Does child have a medically prescribed diet? __________________________________________
Any physical limitations? __________________________________________________________
Is teen subject to sleepwalking, fainting?
_____________________________________________________________
Has teen recently been exposed to contagious disease or conditions, such a mumps, measles, chicken pox,
etc.? If so, date and disease or condition: __________________________________
______________________________
You should be aware of these special medical conditions of my child
________________________________________________________________________________
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