CYO-Medical Information and Consent Form

Medical Information and Consent Form

St. Peter Youth Ministry
Must be filled out to participate in any CYO event
GENERAL INSTRUCTIONS TO PARENTS/GUARDIANS/ADULTS:

1. Please take care in filling out this form. It provides crucial information for caregivers in the event of illness or medical emergency. Accuracy and thoroughness are encouraged.

2. Sections I, II and V are mandatory. Sections III and IV provide you with treatment options in non-emergency situations..
CYO Member's Name CYO Member's Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female
Parent/Guardian's Name: Parent/Guardian's Name: First Last
Parent/Guardian's Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent/Guardian's Phone number: Parent/Guardian's Phone number: - ### - ### ####
Parent/Guardian's Phone secondary number: Parent/Guardian's Phone secondary number: - ### - ### ####
SECTION I -- MEDICAL MATTERS -- MANDATORY

As the Parent/Legal Guardian said above, who is currently associated with St. Peter Youth Ministry, I hereby authorize The Youth Ministers and/ or his/her assistants to carry out the wishes I have named (herein) in areas of emergency medical treatment and other cases of illness. This authorization inclusively extends from September 1, 2018, through August 31, 2019. I hereby warrant that, to the best of my knowledge, said person is in good health, and I assume all responsibility for the health of said person.
Parent/Guardian's Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
SECTION II - EMERGENCY MEDICAL TREATMENT -- MANDATORY

In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the numbers listed herein, contact:
Name Name First Last
Relationship to Child
Phone Phone - ### - ### ####
Family Doctor Name
Doctor's Phone Doctor's Phone - ### - ### ####
Family Health Plan Carrier:
Policy #
Parent/Guardian's Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
SECTION III - OTHER MEDICAL TREATMENT

In the event it comes to the attention of the parish, its officers, directors and agents, and the Archdiocese of New Orleans, chaperones, or representatives associated with the activity that said person becomes ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea, I want to be called collect (with phone charges reversed to myself).
Parent/Guardian's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
SECTION IV - MEDICATIONS

SIGN ONLY THOSE OPTIONS THAT ARE APPLICABLE
Said person is taking medication at present. Said person will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for seeing that the said person takes such medications, including dosage and frequency of dosage, are as follows:
Parent/Guardian's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
I hereby grant permission for non-prescription medication (such as aspirin, throat lozenges, cough syrup) to be given to said person, if deemed appropriate.
Parent/Guardian's Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
NO medication of any type, whether prescription or non-prescription, may be administered to said person unless the situation is life-threatening and emergency treatment is required.
Parent/Guardian's Siignature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Today's Date Today's Date / MM / DD YYYY
SECTION V -- MEDICAL INFORMATION

The parish will take reasonable care to see that the following information will be held in confidence.
Allergic reactions (medications, foods, plants, insects, etc.):
Immunizations
Date of last tetanus/diphtheria immunization: Immunizations
Date of last tetanus/diphtheria immunization: / MM / DD YYYY
Does said person have a medically prescribed diet?
Any physical limitations?
Is said person subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bed-wetting, fainting?
Has said person recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc?
If yes, date and disease or condition:
You should be aware of these special medical conditions of said person:

CYO-Medical Information and Consent Form

CYO-Medical Information and Consent Form

Medical Information and Consent Form

GENERAL INSTRUCTIONS TO PARENTS/GUARDIANS/ADULTS:

SECTION I -- MEDICAL MATTERS -- MANDATORY

SECTION II - EMERGENCY MEDICAL TREATMENT -- MANDATORY

SECTION III - OTHER MEDICAL TREATMENT

SECTION IV - MEDICATIONS SIGN ONLY THOSE OPTIONS THAT ARE APPLICABLE

SECTION V -- MEDICAL INFORMATION

SECTION IV - MEDICATIONS

SIGN ONLY THOSE OPTIONS THAT ARE APPLICABLE