St. Dominic Savio Youth Ministry
Combined Consent and Health Form

 

Parents/Guardians:  Your signature at the end indicates your consent and acceptance of the provisions included on this document.  Please list any special dietary needs on an attached sheet.

 

Name:__________________________________________________________________
Youth Group That You Belong:____________  Age:_______ Gender:_____________
Home Phone: (____)_______________
Father's Name:___________________  Father's Work Phone:(____)_________________
Mother's Name: __________________ Mother's Work Phone: (____)________________
Mailing Address: ________________________________________________________________________
City, State, & Zip:                                                                   E-mail:

________________________________________________________________________

Participation Consent:
(Name of Parent or Guardian) ____________________________ grant permission for my son/ daughter to participate in the 2006-2007 Youth Ministry program.

Liability Waiver:  I will not hold the Silesians of Don Bosco at St. Dominic Savio Parish, St. John Bosco High School, or the program facility responsible in the event of any injury or accident to my son or daughter while participating in the 2006-2007 Youth Ministry program and/ or traveling to and from the program while on field trips.

Statement of Health:  I hereby warrant that, to the best of my knowledge, my child is in good health and able to participate in all program activities.  (Please submit a statement indicating limitations and/ or conditions of which we should be aware.)
____________________________________________________________________________________________________________________________________________________________

Insurance Information
Family Health Insurance Co.: _________________ Policy No.: __________________
 
Medications:  Any medications brought to the program should be clearly labeled and in their original container.  Please list any prescription or approved non-prescription drugs your child is presently taking.  Include product name and physician's instructions on dosage and frequency.
____________________________________________________________________________________________________________________________________________________________

I understand that all prescription medication if is necessary will remain in the possession of the Youth Ministry and be dispensed as prescribed.  I grant permission for non-prescription medication (such as Ibuprofen, Tylenol, throat lozenges, cough syrup) to be given to my child if deemed advisable.

If there are any non-prescription drugs you do not want administered to your child, please list them: ________________________________________________________________________

 

Allergies: (Please write a statement noting all known allergies, including how the child has been treated and with what medication.  If medications are needed occasionally or regularly, please send them with your child in case of need.)
____________________________________________________________________________________________________________________________________________________________

Operations or Serious Injuries (Within the past 18 months)
Operation/ Injury: ___________________________________ Date: ______________
 
Medical Emergency
In case of medical emergency, I understand that a reasonable effort will be made to contact parents or guardian or participants.  In the event that I cannot be reached, I hereby give permission to the physician selected by the Youth Ministry to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named herein.

Model Release: I grant permission for my son/ daughter's image to be used from photos taken during the 2006-2007 Youth Ministry program.

Use of photographs/ video: St. Dominic Savio Parish assure the above-signed guardian that the use of the images of your son/ daughter will be for very limited purposes of publication in the Good News newsletter, on Province and Youth Ministry websites, and for promotion of similar kinds of events or for news reports on this and future similar events.  No matter of manipulation will be employed in the use of these images nor will they be made available for public use beyond the limitations set in these documents.

Signature of Parent of Guardian
I certify that the above information is correct and give permission for my child to be transported via public transportation (i.e. school buses or rental vans) for approved 2006-2007 Youth Ministry program activities; and for the release of medical records to an attending physician in case of illness.

I fully understand the consequences of the foregoing statements and sign this form knowingly, freely, and willingly.  (Your signature must appear below or your child will not be permitted to participate in the 2006-2007 Youth Ministry program.)

Signature: ___________________________________ Date: _____________________