2021 PASCHAL CHALLENGE REGISTRATION Question Title * Participant's Information Last Name First Name Address Address 2 City/Town ZIP/Postal Code Parish Email Address Phone Number Question Title * Camper's Date of Birth Date of Birth Date Question Title * Age Question Title * Participant's Grade (2020-21 school year) 9th 10th 11th 12th Other Question Title * Any medical needs? (i.e. medications, allergies, etc.) Question Title * Any dietary needs? Question Title * Parent/Guardian Information Last Name First Name Address Address 2 City/Town ZIP/Postal Code Phone Number Email Address Cell Phone EMERGENCY MEDICAL AUTHORIZATION (Part 1 OR Part II MUST BE COMPLETED) The purpose of this form is to enable parents and/or guardians to authorize the provision of emergency treatment for the above named participant who becomes ill or injured during an event when parents and/or guardians cannot be reached. Part 1 - To Grant Consent In the event reasonable attempts to contact me at the above listed phone numbers have been unsuccessful, I hereby give my consent for:1. The administration of any treatment deemed necessary by: Question Title * Name of Preferred Physician Name Company Phone Number Question Title * Name of Preferred Dentist Name Company Phone Number or in the event the designated preferred practitioner is unavailable, by another licensed physician or dentist. 2. Transfer participant to: Question Title * Preferred hospital or any hospital reasonably accessible Question Title * This authorization DOES NOT cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.List participant's medical history (include allergies, medications, any physical impairments, etc.) to which a physician and event personnel should be alerted to: Question Title * Signature of Parent and/or Guardian (Typed name authorizes the Diocese of Saint Cloud to provide any emergency medical treatment necessary.) Question Title * Date Date Date Part II - Refusal of Consent Question Title * I DO NOT give my consent for emergency medical treatment of the participant and I wish the authorities to take no action. In the event of illness or injury requiring emergency treatment, I wish the authorities to . . . (Please explain what action you want supervising personnel to take): Question Title * Signature of Parent and/or Guardian (Typed name states the Diocese of Saint Cloud will take no emergency action.) Question Title * Date Date Date Next