EMERGENCY INFORMATION FOR FAMILIES
CHILD'S NAME LEVEL CATECHIST'S NAME (Leave blank)
1_____________________________ _____ ____________________________
Last name First
2:_____________________________ _____ ____________________________
Last name First
3:_____________________________ _____ ____________________________
Last name First
3:_____________________________ _____ ____________________________
Last name First
CONTACT INFORMATION
____________________ __________ ________________ ____________
Name of contact person Phone # Doctor's Name Phone #
__________________ ___________ ___________________ ____________
Name of alternative # 1 Phone # Name of alternative # 2 Phone #
________________________________________________________________________
Hospital Preferred
__________________________ _______________
Parent's Signature Date
MEDICAL RELEASE
In the event that the undersigned, or my (our) authorized physician cannot be reached and in the judgment of Director of Religious Education or other person responsible for the program/group, or other appropriate staff member, there is a necessity for immediate examination and/or treatment of my (our) child. I (we) hereby request and authorize any of the said personnel to obtain for my child such medical services as are deemed necessary. I agree to assume the financial responsibility for any diagnosis/treatment and for medication deemed necessary.
Dates for which release is intended: Year - 2010 -2011
_________________________ ______________
Parent/Guardian's Signature Date