2023-2024 ANNUAL EMERGENCY MEDICAL CARE FORM

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Note: Parents must complete, sign and submit this form prior to the commencement of each Parish Youth Ministry Program year for each child enrolled in a Parish Youth Ministry Program. Parents are responsible for updating the information on this form should changes occur during the Parish Youth Ministry Program year.

Consent to Emergency Medical Care

Name of Child

Parish

Grade

In the event of an emergency, I request that the parish make reasonable attempts to contact me at the following phone number:

I understand that in an emergency, exigent circumstances may prevent the parish from contacting me immediately, or the parish may be unable to reach me. I therefore consent to the parish taking action which it deems necessary to secure emergency medical care/treatment for my child even if I have not been contacted.

I understand that decisions concerning the type of emergency medical care or treatment administered are normally made by health care providers and not by the parish and that exigent circumstances may require the administration of emergency medical care or treatment without my prior consent. However, I have indicated below any treatment preferences I have for my child which the parish may disclose to a health care provider. (Parents/guardians may check and complete any of the following):

My prefered doctor is: *

My prefered dentist is: *

My prefered hospital is: *

The parish may also disclose the following information to a health care provider:

Insurance Information

Allergies or medical facts about my child

Receipt of my consent prior to my child receiving major surgery unless the medical options of two licensed
physicians or dentists, concurring in the necessity for such surgery, are obtained before surgery is performed.
*

Yes

Insurance Company Name
-and-
Policy/Group/Number
*

Please list information regarding allergies your child has, medication your child is taking,
and other medical facts about your child:

I understand that in the event of an emergency, the parish will make reasonable efforts to notify a health care provider of the above-checked information, but I acknowledge that I am responsible for communicating such information to the appropriate medical personnel.

Parent/Guardian Full Name *

Today's Date *

YYYY

Parent/Guardian Email Address *

Submit

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