Parent Medical and Liability Release Statement (one per child)
Diocese of San Bernardino
Child's Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Parent's Name completing this form *
Your answer
Parent's Name completing this form *
Your answer
Phone number *
Your answer
Emergency contact *
Your answer
Emergency contact Phone number *
Your answer
Child's physician name and phone number *
Your answer
Does your child have allergies/disabilities/medical issues? *
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