Adult Medical Release Form

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ADULT MEDICAL RELEASE FORM
(Please print.)
PARTICIPANT’S NAME______________________________________PHONE ____________________
ADDRESS___________________________________________
CITY___________________________________________STATE______________ ZIP_____________
PARISH___________________________________ BIRTH DATE____________ GENDER__________
DOCTOR’S NAME_____________________________________ DR.’S PHONE___________________
INSURANCE COMPANY_____________________________________ POLICY #_______________________
Are there any known allergies to food or medications that those who work with you on this retreat should
be aware of? Yes
NO
____________________________________________________________
If yes, explain:
Are there any known physical, psychological or emotional limitations that would affect your participation in
this event? Yes
No
____________________________________________________________
If yes, explain:
EMERGENCY CONTACT PERSON:
NAME ___________________________ PHONE______________RELATIONSHIP_________________
Release Form
I request that the Roman Catholic Diocese of San Jose, Office Pastoral Ministry, permit me to
participate in the St Julie’s Tijuana Ministry, and its intended activities from July 11-18, 2015. We
will travel by car and van from 366 St. Julie Drive, San Jose, California 95119 to Iglesia de San
Enrique , Calle principal Colonia de Terrassas II, Tijuana, Baja California Norte, Mexico and return
to St. Julie’s in San Jose. I understand we will travel by car and van from the mission to the
worksite each day. I understand that reasonable precautions will be taken to safeguard the health
and well being of the participants. In case of sickness or accident, I authorize and consent to any
x-ray exam, anesthetic, medical, dental or treatment and hospital care to be rendered to me under
the general care and advice of any physician, dentist, or surgeon licensed to practice in any state
or in Mexico. I further understand and agree to be responsible for any such medical, dental and/or
hospital expenses incurred.
Participant’s Signature ___________________________
Date_______________

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