St. Walter Church 130 W. Pine Roselle, IL 601272 Phone: (630)894-2461

MEDICAL PERMISSION FORM

I grant permission for the administration of First Aid to my child, ___________________________  by the people in charge of the event, and those transporting my child to and from the event as their judgment deems advisable, and to make the necessary referrals to qualified physicians for the treatment of illness or accidents of a more serious nature I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery , except when delay in such communication would endanger life. In the case of a medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery if deemed necessary for my child.

Participants Name:
____________________________________         Birth Date:     ____________________

Allergic medication/other?  NO   YES (circle one)
If yes, please describe:
________________________________________________________________________

Medication(s) presently taking:
____________________________         ____________________________ 
 

Insurance Information
Policy in the name of:
______________________________________
Insurance Company
______________________________________
Policy Number:
______________________________________
Identification/Social Security Number:
______________________________________
Authorized Physician:
______________________________________
Phone #:
______________________________________
Parent/Guardian Signature:
______________________________________
Date:
______________________________________
Address:
______________________________________
City, St., Zip   ___________________________
Home Phone: 
______________________________________
Work Phone:
______________________________________
In case of emergency, contact:
______________________________________
Phone Numbers:
______________________________________