Permission and Insurance Release for

Rendu Santa Shop

 

(teen’s name) ______________________ has my permission to participate in the Greater Norwin Area Catholic Senior Youth Ministry is going to Fayette County to work with the Sisters of Charity... on (date) Saturday, December 17, 2011... to be chaperoned/supervised by (chaperones' name) Judy Kunes, Mary Blythe, Dan Lieberum, Kirsten Lieberum etc.

 

I understand that neither Greater Norwin Area Catholic Senior Youth Ministry nor any of it’s agents are responsible for any injury sustained by my child. I accept responsibility for any medical expenses as a result of any such injury sustained.

(Parent or Guardian Signature) _____________________________________________________   

 

                     (phone number)__________________________________  (date)_______________________________

 

Medical Release Purpose

 

To Whom it may concern,

          As a parent and/or guardian. I do hereby authorize the treatment by a qualified and licensed medical doctor of the following minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed.  This authority is granted only after a reasonable effort has been made to reach me.

 

This release is intended for (date)______________________________.  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.

Signed_______________________________________     ____________________________

            (father, mother, legal guardian)                                                                                    (date)

____________________________________________________________________

(address)                                                           (city)                                                                       (state)          (zip)

_________________________________            ______________________________

(home phone number)                                                                                                      (work phone number)

 

Family Physician_____________________________      Phone__________________________

Specific medical allergies, chronic illnesses or other condition:

_____________________________________________________________________

Another person to contact in case of emergency:

_______________________________________     ____________________________ 

(name)                                                                                                                                           (phone)