Life Teen

Youth Name
First Last
Grade:
Age:
Youth Cell #
Parish:
Address
Street Address City State ZIP Code
Name of Parent/Guardian #1
Relation:
Cell Phone#
Email
Name of Parent/Guardian #2
Relation:
Cell Phone#
Email
Emergency Contact Name and Phone #:
The registration fee is $50.00 (T-shirt will NOT be provided). Fee can be paid via the following link: Registration Fee Please make checks payable to: Divine Mercy Catholic Church
Parent/Guardian Digital Signature:
Date
MM slash DD slash YYYY

ANNUAL PARENTAL MEDICAL CONSENT FORM
IN CASE OF AN ACCIDENT OR SERIOUS ILLNESS, THE ABOVE PARISH WILL CONTACT THE PARENT/GUARDIAN LISTED BELOW. IF THE PARISH IS UNABLE TO REACH THEM, OR ANY OTHER PERSON DESIGNATED, THEN I HERBY AUTHORIZE THE CURCH AND ITS REPRESENTATIVES TO CONTACT MY CHILD’S PHYSICIAN AND/OR MAKE ARRANGEMENTS FOR IMMEDIATE EMERGENCY TREATMENT, PAYMENT OR FEES FOR ALL MEDICAL SERVICES WILL BE THE RESPONSIBILITY OF THE PARENT/GUARDIAN. THIS MEDICAL RELEASE IS VALID THROUGH THE ANNUAL DURATION OF LIFE TEEN/YOUTH GROUP MEETINGS AND FOR ALL EVENTS INCLUDED IN THAT TIME. I UNDERSTAND THAT IT IS THE PARENT’S RESPONSIBILITY TO UPDATE THIS FORM AS NECESSARY THROUGHOUT THE YEAR.
Youth’s Name:
First Last
Parent/Guardian’s Name:
Phone
Emergency Contact:
Phone
Family Physician’s Name:
Phone
Insurance Co. Name:
Insurance ID #:
Insurance ID #:
Cardholder’s Name:
HEALTH INFORMATION:
List all medications taken daily and/or regularly:
Youth/participant’s allergies, if any, including medication and food allergies:
Youth/participant’s chronic medical problems (diabetes, epilepsy):
Youth/participant’s other physical restrictions or dietary requirements (if any):
- Yes, I give my permission for my son/daughter to be given over the counter medication when needed.
- No, I do not give my permission for my son/daughter to be given over the counter medication.
Digital Signature of Parent/Guardian
Date
MM slash DD slash YYYY

WHAT DO WE DO?