Digital Medical Form 2023

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Digital Medical Form 2023 - 2024

The Diocese of Lansing, and St. Rita Parish, require a health history and medical release form for participation in all parish programs and activities. Completion of this form fulfills the above requirement for all EDGE and Lifeteen participants for the 2023 - 2024 school year.

Child's name: *

Child's sex: *

Male

Female

Child's birthday: *

YYYY

Child's current age: *

Parent/guardian name: *

Parent/guardian relationship to participant: *

Street Address: *

Primary phone number: *

Secondary phone number:

Student's grade for the 2023 - 2024 academic year: *

My child will be attending: *

EDGE (6-8 grade, 10:00 - 11:00 a.m. on Sundays)

Lifeteen (9-12 grade, 6:00 - 7:30 p.m. on Sundays)

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