Medical Release Form 2019-20
***Families must complete the following form for EACH child to complete registration for St. Theresa Catechesis.***
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Student First Name *
Student Last Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Physician Name *
Physician Phone Number *
In the event of an emergency and you are unable to reach ME, contact this individual instead (full name & phone): *
In case of medical emergency, I, the parent/guardian of this student, give permission to St. Theresa Catholic Parish to obtain all necessary medical care prescribed by the nearest emergency room.  This care may be given under whatever conditions are necessary to preserve life, limb, or well-being of my dependent. *
Required
I fully understand that my child must abide by all rules governing conduct and safety while attending St. Theresa Parish Evangelization & Catechesis Program activities.  See the behavior expectations for participation in our programs on our website. *
Required
Parent/Guardian Name *
Parent/Guardian Phone Number *
Parent/Guardian Email Address *
Please note any allergies, medical conditions, behavioral conditions, or learning differences your child may have. (Please indicate 'N/A' if there is nothing to note.) *
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