Form B - Consent To Participate And Consent For Emergency Medical Treatment

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FORM B - Consent to Participate and Consent for Emergency Medical Treatment
Diocese of Fort Worth and/or the Parish of ____________________________________________
Consent to Participate and Consent for Emergency Medical Treatment
I, _______________________________________ grant permission for my child, _______________________________________
Parent or guardian’s name
Participant’s Name
to participate in the below described parish event. This activity will take place under the guidance and direction of parish employees
and/or volunteers from the above named parish.
A brief description of the activity follows:
Description of event:
Date of event:
Destination of event:
Individual(s) in charge:
|
Estimated time of departure and return:
Mode of transportation to and from event:
Transportation to/from event is the responsibility of the participant
During this event, I give permission for either of the adults named above in charge of the event
to consent to emergency medical or surgical treatment for
.
Name of minor
There are no changes to insurance or medical information since I last filled out Form A for my child named above.
The following changes to insurance and medical information since I last filled out Form A for my child named above are:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
If Guardian of Conservator is signing this consent form, please state the name of parent, if known______________________________
Emergency Contact Name__________________________________Cell__________________________________
Do you text?
Yes
No
Please Print Parent/Guardian/Conservator Name__________________________________________________________________
Cell Phone__________________________________________ Do you text? Yes
No
Home Phone__________________________________________
Parent/Guardian/Conservator Name
Date
By checking this box
and typing your name above, you have agreed that this is your electronic signature.
If you do not wish to sign this document electronically, you must leave the check box and signature fields blank, Please print the
document, sign, and mail to your parish.
This form “CONSENT TO PARTICIPATE and CONSENT FOR EMERGENCY MEDICAL TREATMENT” must be attached to the
Parent/Guardian/Conservator Permission, Liability Waiver, and Medical Information (FORM A) for each event attended. Forms A and B
must travel to and from each trip away from the church. Forms OA and OB are required for all Out of State events.
4.3a

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