APPENDIX A: Church of St. Thérèse Annual Medical Release Form

Question Title

* 1. Please provide the following information:

Participant's Name

Gender

Date of Birth

Soc. Security #

Home Address

City

State

Zip

Home Phone

Work Phone

Name of Parent/Guardian

Insurance Company

Policy Holder's Name

Relationship to Policy Holder

Policy Number

In Case of an Emergency, please notify:

Home Number

Work Number

Mobile Phone

Question Title

* 2. Does your child have any allergies?

Yes

No

Question Title

* 3. If "yes," please list allegies:

Question Title

* 4. Does your child have medications, of any type, with her him?

Yes

No

Question Title

* 5. If "yes," please list the medication(s) your child has.

Question Title

* 6. Is there any other physical or emotional condition of which we need to be aware? Please explain.

Question Title

* 7. In the event of an emergency, I give authority to the accompanying adults to authorize treatment. I understand that an attempt to notify me will be made before any treatment is authorized. I understand that providing my name and parishioner number here constitutes an electronic signature.

Parent/Guardian Name

Parishioner Number (found on your parish offering envelopes)

Date