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Health Form
[ HEALTH FORM ]
Dixie Catholic Faith Formation Religious Education Health Form.
1 per individual
Name:
Birth Date:
Grade:
Address:
Phone Number:
Sex:
Select an option
Male
Female
Emergency Contact Information:
Father / Guardian:
Phone Number:
Cell Phone:
Mother / Guardian:
Phone Number:
Cell Phone:
Insurance Information:
Emergency Contact:
Phone Number:
Cell Phone:
Name of Insurance Co.:
Policy #:
Health Information:
Family Doctor:
Phone
Any Pre-Existing or Present Medical Conditions: (Please Check)
Heart Condition
/ Diabetes
/ Epilepsy
/ Asthma
Allergies:
Parent Medical and Liability Release Statement
In case if any medical emergency, I understand that every effort will be made to contact immediately the parents/guardians or any other contact person listed on this form regarding this child participating in the Religious Education Program. In the event that I cannot be reached, I hereby give permission to the physician selected by a Religious Education Staff member to hospitalize, secure proper medical treatment for, and to order injection, anesthesia or surgery for my child as named herein as deemed necessary.
The UNDERSIGNED shall be liable and agree to pay all costs and expenses incurred in connection with such medical services rendered to the aforementioned child pursuant to this authorization.
I understand all reasonable safety precaution will be taken at all times by Dixie Catholic Faith Formation and its agents during the Religious Education Classes and events. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold St. Paul, St Lawrence, Mary Queen of Peace, or Incarnation Catholic Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
Signature of Parent or Guardian:
Date:
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