Diocese Of Boise Youth Permission & Medical Release Form printable pdf download

DIOCESE OF BOISE YOUTH PERMISSION & MEDICAL RELEASE FORM

EVENT: ________________________________________

Date: _____________________

PLEASE PRINT

Youth’s Name ______________________________________________________

Mother or legal Guardian (circle one) Full Name _____________________________________________

Father or legal Guardian (circle one) Full Name _____________________________________________

Date of Birth _________/________/_________

Male

Female (please circle)

I, THE PARENT (GUARDIAN) OF THE ABOVE NAMED CHILD, HEREBY, GIVE MY PERMISSION FOR HIS/HER PARTICIPATION IN THE YOUTH ACTIVITY

NAMED ABOVE. I AGREE TO DIRECT MY CHILD TO COOPERATE AND CONFORM TO DIRECTIONS AND INSTRUCTIONS OF PARISH, SCHOOL AND

DIOCESAN PERSONNEL RESPONSIBLE FOR THIS ACTIVITY.

I agree that in the event my child is injured as a result of his/her participation in the above named activity, including organized

transportation to and from this activity, whether or not caused by the negligence (active or passive) of the parish/school or

diocesan youth activity program, or any of its agents or employees, recourse for the payment of any resulting hospital, medical,

or related costs will first be paid by parent or guardian insurance or any available benefit plan of parent or guardian.

I am not aware of any medical condition of my child, which would render it inappropriate for him/her to participate

in any activity.

I, hereby, give permission to the medical personnel selected by the youth activity supervisory personnel present, should

parent/guardian not be available for permission or consultation, to render medical treatment deemed necessary and appropriate

by the physician, R.N. or dentist.

I understand that during the activity my child may be transported to and from the activity site via a personal vehicle.

Parents/guardians of participants are advised that photographs or videotape of participants maybe used in publications,

websites or other materials produced periodically by Diocese of Boise and/or Office of Youth Ministry or local parish.

(Participants would not be identified, however, without specific written consent. Parents/guardians who do not wish their

child(ren) to be photographed or filmed should so notify the parish/Office in writing. Please note that the Office has no control

over the use of photographs or film taken by media that may be covering the event in which your child(ren) participate.

MEDICAL HISTORY & INFORMATION

Allergies_______________________________________________________________________________________________

Date of last tetanus shot (month/year) __________/_________

Physical Impairments/limitations __________________________________________________________________

Other health issues to aware of (allergies, illness etc.)

__________________________________________________________________________________________

______________________________________________________________________________________________

__________________________________________________________________________________________

Diocese Of Boise Youth Permission & Medical Release Form