2019-2020 Medical Form

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St. Ann Youth Ministry Program

We ask that everyone fill this out completely so we may use this information for all events your child attends during the 2019-2020 academic year. You only need to fill it out once each school year unless your information changes. If any of the following information changes, please fill out a new form. Thank you.

Name of Student *

Birthday *

YYYY

Age *

Sex *

Address *

City *

State *

Zip Code *

High School Graduation Year *

High School *

Parent Name *

Parent Cell Phone *

Parent Email *

I. The undersigned does hereby give permission for our (my) child to attend and participate in activities sponsored by the St. Ann's YOUTH MINISTRY Programs. II. We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any licensed physician or dentist. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered. III. I hereby grant permission for non-prescription medication to be given, if deemed appropriate. IV. Should it be necessary for our (my) child to return home due to medical reasons, behavioral reasons, or otherwise the undersigned shall assume all transportation costs. V. The undersigned does also give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the St. Ann's YOUTH MINISTRY Programs. *

I agree

Required

Insurance Provider *

Name with Insurance *

Insurance Number *

Group Number *

Allergies

I give permission for my teen to be photographed during activities with St. Ann’s Youth Ministry. I understand that said photos/videos may be used for future Youth Ministry publications within the St Ann’s Community and social media. *

I agree

I give permission for Youth Ministry Staff and volunteers to communicate with my teen via e-mail, phone calls, and social media. *

I agree

In signing this form, I the parent, certify that all information contained herein is true and accurate to the best of my knowledge. Please type your name. *

Today's Date *

YYYY

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