Child Comprehensive Medical Release & Permission Form
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Diocese of La Crosse
Child Comprehensive Medical Release & Permission Form
Contact Information
Name: _____________________________________________ Date of Birth: _____________________
Male
Female
Parish Name/City: ______________________________________________ Year of Graduation: ____________________
Address: __________________________________ City: _________________________ State: ______ Zip: ___________
Phone #: _______________________ (Home) E-mail Address: _______________________________________________
Mother’s name: _______________________ Phone: (H) _______________ (W) _______________ (C)_______________
Father’s name: ________________________ Phone: (H) _______________ (W) _______________ (C)_______________
Emergency Contact: _________________________________________ Relationship: _____________________________
Phone: (H) ___________________ (W) ___________________ (C)___________________
Physician: __________________________ Clinic/Hospital: _______________________ Office Phone: _______________
Medical Insurance Company: __________________________________________ Policy #: _________________
Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness,
limitation, handicap, disability, or condition to which the participant is subject and of which the staff should be aware, and what, if any
action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of
medications and dosages that must be taken. The parish/Diocese of La Crosse will take reasonable care to see that the following
information will be held in confidence. Some activities may be physically strenuous (especially mission trips and camps). If you desire
to limit a participant’s participation in any way, please submit your wishes in writing prior to the trip.
1. Is the participant in good health and able to participate in normal activities?
Yes
No
If not, please submit a statement indicating limitations and/or restrictions.
2. Please give the date of the participant’s most recent physical examination: ________________
3. Immunization History (Please give dates)
Date of last Tetanus Shot: _____________
Please fill in below only for foreign mission trips:
DPT ________
DPT Booster _________
Polio Booster _________
Polio Series _________
Other, if any necessary, for specific trip: ___________________________________________________
*Note: You are responsible for consulting your doctor about immunizations necessary for foreign missions.
4. Allergies
Pollens _____
Medications _____
Food _____
Insect bites _____
Please note specifics: __________________________________________________________
5. Has the participant ever suffered from or been treated for any of the following:
Asthma_____
Epilepsy/seizure disorder _____
Heart trouble _____
Diabetes _____
Frequently upset stomach _____
Physical handicap _____
Depression _____
Emotional/Mental Disorder _____
Other ____________________
6. Operations, serious injuries, or major illnesses in the past year:
__________________________________________________ Dates: _______________
7. Is the participant subject to chronic homesickness, emotional reactions to new situations (sleepwalking, bedwetting,
fainting)? _______________________________________________________________________________
8. Has the participant recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox,
etc.? If so, list date and disease or condition: ___________________________________________________
9. Does the participant have a medically prescribed diet?
Yes
No
10. The participant is a
swimmer
non-swimmer
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