Emergency Medical Release & Permission Form

Emergency Medical Release & Permission Form

All Saints 2022 - 2023
Youth Name: *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birthday: *

Month Day Year
E-mail
Student Cell Phone:
Student Home Phone:
School: *
Grade:
Father's Name:

First Name Last Name
Mother's Name:

First Name Last Name
Parent's Home Phone:
Parent's Cell Phone:
Parent's Email:
Other Contact:

First Name Last Name
Other Contact Phone:

Area Code Phone Number
Other Contact Relationship to Child:
Please complete this form and return it at the first Religious Ed class. It will remain on file with the Youth Ministry for the 2018 - 2019 school year.

(The purpose of the following medical release form is to enable parents and gurdians to authorize the provision of emergency treatment for minors who become ill or injured under All Saints Parish and High 5 Youth Group authority, when parents and guardians cannot be reached.)

Medical Information
In the event reasonable attempts to contact the parents listed above using the "Home Phone" or "Cell Phone" listed or reasonable attempts to contact the "Other Contact" using the "Other Contact Phone" have been unsuccessful, I herby give my consent for the administration of ay treatment deemed necessary to:
Preferred Physician:

First Name Last Name Suffix
Preferred Dentist:

First Name Last Name Suffix
Preferred Hospital:
**NOTE** In the event that the designated practitioner is not available, permission is granted to another licensed physician or dentist.

**NOTE** If hospital designated above is deemed to far away by medical professionals, permission is given to transfer minor to the nearest hospital.
List facts concerning the child's medical history, including allergies, medications being taken, and any physical impairment to which a physician should be alerted:

Authorization Information
Also, as parent or legal guardian, I give "Youth Name" listed above my permission to participate in High 5 Youth Ministry activities and trips. I agree to assume full responsibility for bodily injury, loss of personal property, and expenses therof, if they should occur as the result of my youth's negligence. In consideration for my youth's participation, I further agree not to hold All Saints Parish, the Coordinator of Youth Ministry or Youth Ministry Volunteers to claims of ordinary negligence. I also agree that pictures taken at functions sponsored by All Saints Parish can be posted on the Parish Website.
Electronic Signature of Parent or Legal Guardian:

If you would like to submit this form On-Line, please use your mouse or mousepad to sign in this area. Clear
Signature of Parent or Legal Guardian: _______________________________________________
If you will be printing this form and returning it to your child's PRE class, please sign on the line above.
Date: *

Month Day Year
Parent (s) Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent Volunteer Information
Please check one or several of the following events that you would be able to help with:

Youth Group Team Oktoberfest Christmas Caroling Famine Experience Walk for Life on Good Friday CYO
Please call the office at (419) 595-2567 or email Kathy Reinhart at kathy.allsaints@gmail.com if you have any questions, comments, or concerns.

Thank you for all you do to make things happen for our youth. You are the first and primary youth minister in their life and what a privilege it is for us that they are involved in parsh life and youth ministry.

May God bless you and your family abundantly.
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