1 ANNUAL MEDICAL INFORMATION FORM

ANNUAL MEDICAL INFORMATION FORM
Child’s Name______________________________________________________________________________________
Address____________________________________________________City,State______________________________Zip_________
Sex ____________________________Date of Birth ____________________________________Age _______ Grade _____________
School ______________________________________________________________________________________________________
Doctor’s Name____________________________________________________________ Phone Number________________________
Father/Guardian’s full name:____________________________________________________________________________________
Home Phone :_______________________________________ Cell Phone ______________________________________________
Home address:________________________________________________________________________________________________
Place of business/address:___________________________________________________ Phone : ___________________________
Mother/Guardian’s full name:____________________________________________________________________________________
Home Phone:________________________________________ Cell Phone ______________________________________________
Home address:________________________________________________________________________________________________
Place of business/address:___________________________________________________ Phone :____________________________
Relative or friend to contact if unable to reach parent/guardian in the event of emergency:
Name & Relationship:__________________________________________________________________________________________
Phone _____________________________________________________________________________________________________
Insurance Carrier:_____________________________________________________________________________________________
Insurance Policy Number:______________________________________________________________________________________
Insurance is provided by which parent and/or place of employment? ____________________________________________________
Address and Phone Number of Company:__________________________________________________________________________
MEDICATIONS: (EITHER A PHYSICIAN’S PRESCRIPTION OR A PARENT NOTE MUST ACCOMPANY ALL MEDICATIONS.
PRESCRIPTION / NOTE SHOULD BE ATTACHED TO THIS FORM.) My child is taking the following medication(s):
Description ________________________________________________________________Dosage___________________________
Description ________________________________________________________________Dosage___________________________
I hereby grant permission for non-prescription medications to be given, if deemed appropriate.
Drug Allergies: ______________________________________________________________________________________________
Other Allergies (food, plants, insects, etc.): ________________________________________________________________________
Other known diseases, disorders, or disabilities: ____________________________________________________________________
Revised 8/2007
Annual Medical Information Form
1
If you would like your youth to participate in parish activities, please sign and return the following statement of consent
and release of liability. As parent or legal guardian, you remain fully responsible for any legal responsibility which may
result from any personal actions taken by your youth.
In consideration for the opportunity for my child to participate in parish activities, and fully recognizing that such an
undertaking involves an element of risk, we assume all risks and hazards incidental to such participation and do hereby
release, absolve, indemnify and agree to hold harmless the Diocese of Pensacola-Tallahassee and
______________________________Parish, and their employees, agents, volunteers, and other persons acting on their
behalf. Neither the Diocese of Pensacola-Tallahassee, _____________________________ Parish, nor said agents,
employees, or volunteers, shall be held financially responsible for any injury, illness or death incurred as a direct or
indirect result of this activity. We the undersigned have read this release and understand all its terms and execute it
voluntarily and with full knowledge of its significance.
EMERGENCY MEDICAL TREATMENT: In the event of an emergency, I/we hereby authorize the Diocese of
Pensacola-Tallahassee, and ______________________________ Parish, through its authorized representatives, to
transport my child to a hospital or other doctor’s office or medical facility for emergency medical attention. I/We
additionally authorize such representatives of the Diocese and/or School to obtain and give consent to whatever medical
treatment the representative deems necessary, including the administering of anesthetic and surgery, and do hereby release
the Diocese and ________________________________Parish, and their authorized representatives from any and all
claims which may arise from the above-referenced obtaining and consenting to medical treatment. I/We wish to be
advised, if possible, prior to the providing of any non-emergency medical treatment by any physician or hospital.
Finally, I/we hereby give permission for the Diocese of Pensacola-Tallahassee and any of its affiliated organizations,
including, but not limited to The Florida Catholic, to use the name of my child and/or his/her photograph for promotional,
news, or public relations purposes in print and/or electronic media.
________________________________________________________
Print Parent/Guardian Name
________________________________________________________
___________________
Signature of Parent/Guardian
Date
This form is to be kept at the parish and renewed annually
Revised 8/2007
Annual Medical Information Form
2