Student or Youth Emergency Information
STUDENT OR YOUTH EMERGENCY INFORMATION
ST. RITA CATHOLIC CHURCH, ROCKFORD ILLINOIS
Only ONE EMERGENCY INFORMATION form per family unit is necessary.

Filling this out and typing name/date at the bottom gives your electronic signature. This document only needs to be filled out the first time an off-campus activity is done through St. Rita Youth Ministry.

FAMILY NAME *
Your answer
FULL NAME OF CHILD 1, SEX, DATE OF BIRTH, SPECIAL HEALTH CONDITIONS (DESCRIBE) OR MEDICATION PRESCRIBED OR DIETARY NEEDS *
Your answer
FULL NAME OF CHILD 2, SEX, DATE OF BIRTH, SPECIAL HEALTH CONDITIONS (DESCRIBE) OR MEDICATION PRESCRIBED OR DIETARY NEEDS
Your answer
FULL NAME OF CHILD 3, SEX, DATE OF BIRTH, SPECIAL HEALTH CONDITIONS (DESCRIBE) OR MEDICATION PRESCRIBED OR DIETARY NEEDS
Your answer
FULL NAME OF CHILD 4, SEX, DATE OF BIRTH, SPECIAL HEALTH CONDITIONS (DESCRIBE) OR MEDICATION PRESCRIBED OR DIETARY NEEDS
Your answer
FULL NAME OF CHILD 5, SEX, DATE OF BIRTH, SPECIAL HEALTH CONDITIONS (DESCRIBE) OR MEDICATION PRESCRIBED OR DIETARY NEEDS
Your answer
Home Address *
Your answer
Phone number *
Your answer
Name of Mother/Guardian, Place of employment, cell phone number *
Your answer
Name of Father/Guardian, Place of employment, cell phone number *
Your answer
If divorced, name of legal custodial parent:
Your answer
Do Mother/Father have joint custody?
If custodial parent cannot be reached, may we contact non-custodial parent?
RESPONSIBLE ADULT(s) who have agreed to assume responsibility for child, if parent/guardian cannot be reached. Name, Address, Phone, Relationship to Child *
Your answer
Physician of Choice, address, phone number
Your answer
Hospital of Choice, address, phone number
Your answer
If I, or responsible adult, and physician of choice, as indicated above, cannot be reached in an emergency and immediate medical and/or hospital attention is indicated I hereby authorize the transporting of my child to a hospital or physician for treatment. *
Email *
Your answer
By typing today's date and full name of Parent/Guardian, you are giving an electronic signature on this document. *
Your answer
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