QUEEN OF ALL SAINTS FAITH FORMATION REGISTRATION 2018

Sunday Classes begin 9/23/18, Tuesday Classes begin 9/25/18   WELCOME MASS  9/30 at 10:30am

          FORMS MUST BE RETURNED BY SEPTEMBER 15, 2018-Please be sure to sign back page!

                                         EMERGENCY HEALTH INFORMATION

Student(s) name_______________________________________________________________________Grade(s)__________

In the event of an illness or injury, or special circumstances, Queen of All Saints will release your student ONLY to those adults (other than parents) below:

_______________________________________________   _____________________  _________________ _______________

NAME                                                                                                                                         CELL PHONE                                            HOME PHONE                             RELATIONSHIP

_______________________________________________   _____________________  _________________ _______________

NAME                                                                                                                                         CELL PHONE                                            HOME PHONE                             RELATIONSHIP

_______________________________________________   _____________________  _________________ _______________

NAME                                                                                                                                         CELL PHONE                                            HOME PHONE                             RELATIONSHIP

In real emergencies call:  Dr._____________________________________  Phone________________________ Or any physician available    Yes___ No___

Health Plan Name___________________________________   Number_______________________________

Hospital you use:_____________________________________________________

Special Medical Conditions/Allergies:_________________________________________________________

Medications:_____________________________________________________________________________

Special Learning Challenges Known:_________________________________________________________

Do we have your permission to inform the child’s catechist of the above conditions, if any?  Yes_______   No_________

I/We authorize an adult, appointed by the Faith Formation Office, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.  The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned minor pursuant to the authorization.

Should it be necessary for our/my child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

 

Parent/Guardian Signature                                                                        Date                                                                                                                          

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