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Parent Medical and Permission Form

Parents/Guardians of Minors - Please Complete and Submit the Form Data Below
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  Name of Minor REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to You REQUIRED Please fill out this field. Please enter valid data.
  
  Address of Minor REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  1st Emergency Contact
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Minor REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  2nd Emergency Contact
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Minor REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Family Physician
  
  Name REQUIRED Please fill out this field. Please enter valid data.
  
  Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Phone Number REQUIRED Please fill out this field. Please enter a phone number.
  
  Health Insurance Data
  
  Company REQUIRED Please fill out this field. Please enter valid data.
  
  Policy REQUIRED Please fill out this field. Please enter valid data.
  
  Group REQUIRED Please fill out this field. Please enter valid data.
  
  Contract Please enter valid data.
  
  List allergies, medication, contacts, or other pertinent information: REQUIRED Please fill out this field.
  
  This Release Form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.
  
  Your son, daughter, or legal ward is eligible to participate in a Church-sponsored activity requiring transportation to St. John The Evanglist Parish in Ishpeming, MI. This activity will take place under the guidance and supervision of adult chaperones. A brief description of the activity follows:
  
  Name of Event: Youth Encounter weekend retreat
  
  Destination: St. John The Evangelist Parish, Ishpeming, MI 49849
  (906) 486-6212
  
  Designated Supervisor of Activity: Father Ryan Ford
  
  Date and Time of Activity: Friday, April 9th, 2021 at 6:30 p.m. Eastern Time
  through Sunday, April 11th, 2021 at 6:30 p.m. Eastern Time .
  
  Method of Transportation: Carpooling
  
  Cost: $35
  
  If you would like your child or ward to participate in this event, please read and acknowledge the following statement of consent and release of liability. As parent or legal guardian, you remain fully responsible for the actions and conduct of your child.
  
  I hereby consent to participation by my son, daughter, or legal ward in the event described above. I understand that this event will take place on parish grounds and that my child will be under the supervision of designated adults on the stated dates. I further consent to the conditions stated above on participation in this event, including the method of transportation.
  
  In consideration of my child being allowed to participate in this activity, I hereby agree on behalf of myself and my child, to release the individuals in charge, the Roman Catholic Diocese of Marquette, St. John The Evangelist parish, and any and all affiliated organizations, their employees, agents and representatives, including volunteer drivers (collectively “Releases”) from any and all claims, including negligence, which may be asserted by me or my child, or on behalf of my child, arising from or relating to my child’s participation in this activity. In the event this release on behalf of myself and/or my child is held to be invalid or unenforceable, I hereby agree to indemnify and hold harmless Releases from any and all claims, including negligence, which may be asserted by me or my child, or on behalf of my child, arising from or relating to my child’s participation in the activity.
  
  This release or indemnification does not apply to claims for intentional misconduct or gross negligence; nor does this release or indemnification apply to the extent of commercial insurance coverage for any claim, but this Release or Indemnification shall apply to the extent of any self-insurance or deductible applicable to any claim.
  
  By clicking below, I am providing my consent.
  I Agree Please select this field.
  
  Person Authorizing This Form Please enter valid data.
  
  Email For Record of This Consent REQUIRED Please fill out this field. Please enter an email address.
  
  Submit
  
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