2018-2019 ANNUAL EMERGENCY MEDICAL CARE FORM
Note: Parents/legal guardians must complete, sign and submit this form prior to the commencement of each Parish Youth Ministry Program year for each child enrolled in a Parish Youth Ministry Program. Parents are responsible for updating the information on this form should changes occur during the Parish Youth Ministry Program year.
Email address *
Part I. Consent to Emergency Medical Care
This form must be completed by a Parent/Guardian of the participant and verified by phone. to request a printable version of this form, contact the St. Charles Office of Youth Ministry
Name of Child: *
Your answer
Grade *
In the event of an emergency, I request that the parish make reasonable attempts to contact me at the following phone number: *
Your answer
Secondary phone number
Your answer
Secondary Emergency Contact Name (other parent/adult): *
Your answer
Secondary Emergency Contact Phone Number: *
Your answer
I understand that in an emergency, exigent circumstances may prevent the parish from contacting me immediately, or the parish may be unable to reach me. I therefore consent to the parish taking action which it deems necessary to secure emergency medical care/treatment for my child even if I have not been contacted. *
Required
I understand that decisions concerning the type of emergency medical care or treatment administered are normally made by health care providers and not by the parish and that exigent circumstances may require the administration of emergency medical care or treatment without my prior consent. However, I have indicated below any treatment preferences I have for my child which the parish may disclose to a health care provider. (Parents/guardians may complete any of the following below): *
Required
Preferred Physician:
Your answer
Preferred Dentist:
Your answer
Receipt of my consent prior to my child receiving major surgery unless the medical options of two licensed physicians or dentists, concurring in the necessity for such surgery, are obtained before surgery is performed.
Other:
Your answer
The parish may also disclose the following information to a health care provider *
Required
Insurance Company Name:
Your answer
Policy/Group/Claim No.:
Your answer
The following information regarding allergies my child has, medication my child is taking, and other medical facts about my child:
Your answer
Choose one: *
Required
I understand that in the event of an emergency, the parish will make reasonable efforts to notify a health care provider of the above-checked information, but I acknowledge that I am responsible for communicating such information to the appropriate medical personnel. *
Required
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