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Parish School of Religion
Medical Permission Form
Updated 10-30-2003

ST. IGNATIUS OF LOYOLA PARISH YOUTH GROUP MEDICAL/PERMISSION FORM

Release and indemnification agreement, medical power of attorney, and medical information for all Youth Events/Activities, sponsored by St. Ignatius Parish, from June 1, 2005 through May 31, 2006 under the direction of Fr. Thomas Bolte, Kris Schoettmer, Frank Barlag, Patty Jo Limle, Tom/Carol Riesser, Jim/Lisa Kramer, Dave Byard, Mary Ann Bosse, Paul/Geri Tengler, Joe Zirkelbach and those specifically authorized by Fr. Bolte, pastor of St. Ignatius Church.

This form, filled out once, will cover all activities and events during the above calendar dates. It will be kept on file in the Parish Office and copies will accompany any event taking place off Church property, so that phone numbers and medical information are available in the event of any type of problems, difficulty or emergency.

1. I, the lawful parent or guardian of ____________________________________________________release from all liability and indemnity and hold harmless the Archbishop of Cincinnati both individually and as trustee for the Archdiocese of Cincinnati and all parishes within the Archdiocese and the employees and volunteers of the Archdiocese of St. Ignatius parish, from all liability arising from or related to any injury incurred by my child while participating in or traveling to or from the activity.
2. I agree to instruct my child to cooperate and show respect to the persons in charge of the specific activity.
3. In the event of a medical emergency, the authorized persons will make every reasonable attempt to contact me as soon as possible.
If I, or the emergency contact listed below, is unable to be contacted, I appoint the authorized persons listed above to give consent and authorization to any physician, dentist, hospital or other person or institution pertaining to emergency medication, medical or dental treatment, diagnostic or surgical procedure or any other emergency action as shall be deemed necessary or appropriate for the best interest of my child.

I have carefully read this statement and my signature acknowledges that I fully understand its content and meaning.

________________________________________________________ ____________________________________
(parent's signature) (printed name)

_________________________ ___________________/ _____________________________________
(date) (home phone) (work number(s))

_______________________________________ __________________________ __________________________
(street address) (city) (zip code)

_________________________________________________________ ___________________________________ (emergency contact not living at above address) (Home and/or work phone)

MEDICAL INFORMATION (Please Print)

Child's full name _______________________________________ Birthdate ____________________________

Allergies __________________________________________________________________

Medications _______________________________________________________________

Chronic Conditions (e.g. epilepsy, diabetes) __________________________________________________________

Medical Insurance Co. __________________________________________________
Policy # _________________

Member's Name ___________________________________________________________________

Family Doctor _________________________________________________________
Phone __________________

This form must be completed, signed and on file with the St. Ignatius Parish Office before youth can participate in any activity.