Medical Information and Release Form

Medical Information

In many cases, our staff and volunteers are not familiar with the medical, physical, and/or emotional history of each participant. Please share ANY information relating to the participant in detail. BE AS SPECIFIC AS POSSIBLE.

Teen's First and Last Name REQUIRED Please fill out this field. Please enter valid data.

Does the participant have any dietary restrictions? REQUIRED YES NO Please fill out this field.

If yes, select any restrictions that apply to this participant: Gluten-free Peanut-free Other

List any other dietary restrictions (i.e. vegetarian, allergies, etc.) Please enter valid data.

Is the participant allergic to anything? REQUIRED YES NO Please fill out this field.

List any details of allergies below (this may include food allergies, allergies to specific medications or chemicals, allergies to any substances): Please enter valid data.

Is the participant currently taking or has taken any prescription medication in the last 6 months? REQUIRED YES NO Please fill out this field.

List the specific prescription medications, reasons for medication, and daily dosage. Indicate if the medication is currently being administered. Please enter valid data.

Does the participant have any emotional, physical or sensory conditions? REQUIRED YES NO Please fill out this field.

List any physical and/or sensory conditions of which we should be aware or of which need special accommodations (e.g. hearing loss, visual impairment, mobility). Please enter valid data.

Release of Liability and Medical Release

As parent and/or legal guardian I remain legally responsible for any personal actions taken by the above named minor. I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend the Catholic Diocese of Richmond, its employees and agents, chaperons, or representatives associated with this event from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate the Diocese, its employees and agents and chaperons, or representatives associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of the Diocese.

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of any emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers I give permission for the noted emergency contact to be notified. I will not hold the Diocese of Richmond responsible for authorizing any medical treatment beyond necessary transportation to the hospital.

Digital Signature (Just type full name) REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.

Use of Pictures and/or Video

I give permission for pictures and/or video of my child (named above) engaged in activities related any Church event to have their pictures posted in the St. Andrew’s Catholic Church publications or websites. Names of participants will not be used without expressed permission from the parent or guardian. If no box is checked below, the assumes you give permission.

Choose ONE REQUIRED YES NO PLEASE CONTACT ME FOR EACH CASE Please fill out this field.

Digital Signature (Just type full name) REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.