2020-21 Medical & Media Release Forms
Email address *
Medical Treatment Authorization
To Whom It May Concern: As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed physician of any condition, which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.
Name of 1st Child & Relationship to You *
Name of 2nd Child & Relationship to You
Name of 3rd Child & Relationship to You
Name of 4th Child & Relationship to You
Name of 5th Child & Relationship to You
Reason For Which Release Is Intended:
All Programming for Holy Redeemer Parish 2012-2021 Year
Address of Child *
Emergency Phone *
Emergency Contact's Name *
Emergency Contact's Relationship to Child *
Family Physician
Family Physician Phone
Family Physician Address
List allergies, medications, medical conditions, contacts, or other pertinent comments for Child 1: (if none, write none) *
List allergies, medications, medical conditions, contacts, or other pertinent comments for Child 2:
List allergies, medications, medical conditions, contacts, or other pertinent comments for Child 3:
List allergies, medications, medical conditions, contacts, or other pertinent comments for Child 4:
List allergies, medications, medical conditions, contacts, or other pertinent comments for Child 5:
Health Insurance Data
Health Insurance Company Name
Health Insurance Company Address
Health Insurance Policy #
Health Insurance Group #
Health Insurance Contract
Authorization & Signature
I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility.

This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician.
Printed Name *
Date *
MM
/
DD
/
YYYY
Signature of Parent/Guardian (leave blank: needs to be signed in person)(must be signed in person before child can participate in any programs)
Media Relations/Promotions Release Form 2019/2020
Child(rens) Name(s) *
RELEASE
IF PERSON BEING USED IN THE MATERIAL IS UNDER 18 YEARS OF AGE, PARENT OR LEGAL GUARDIAN MUST SIGN THE FORM.

I/we give my/our permission to the Roman Catholic Diocese of Grand Rapids, Michigan, (the Diocese) and all entities, representatives, employees, and agents operating under its authority to use, without prior notice, my name or my minor child's name, city and state, and/or audio, video(s), photo(s), and/or any other likeness and to use statements made by or attributed to me or my child relating to the Diocese, without compensation, for publications, including any written copy that may be created in connection therewith. I/we agree that my/our signature(s) below releases any and all claims against the Roman Catholic Diocese of Grand Rapids, or its associated entities related to or arising out of the Diocese's use of the stated items as media relations/promotional material(s).
I grant permission for release *
Required
Signature of Individual (if 18 or older) Leave blank: needs to be signed in person!
Date
MM
/
DD
/
YYYY
Printed Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian LEAVE BLANK: needs to be signed in person
(Must be signed in person)
Date
MM
/
DD
/
YYYY
If individual referenced above is under 18, please indicate your relationship to that person
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy