Emergency Medical Document Form

Emergency Medical Information

Name of Child(Required)

First Last

Child's Age(Required)

Medical Information

In the event a participant becomes ill or injured, I authorize St. Faustina Catholic Parish’s Parochial Administrator, Rev. Ramon Bolatete, or the Director of Faith Formation, Marylu Mariniello or representatives to obtain medical attention at a physician’s office, hospital or by an EMT or other emergency medical services. I understand that every effort will be made to reach me before medical permission is given to treat my child. The participant is covered by the following medical insurance:

Insurance Co. Name(Required)

Group #(Required)

Allergies(Required)

Chronic Medical Problems(Required)

Medications taken by child(Required)

Other Important Medical Information(Required)

Name of Parent/ Guardian(Required)

By typing your name in this box, you acknowledge that it constitutes your electronic signature and confirms your agreement to the terms specified

Today's Date(Required)

Home Phone of Parent/ Guardian(Required)

Cell Phone of Parent/ Guardian(Required)

Work Phone of Parent/ Guardian(Required)

Emergency Contact Person

(When parent/guardian cannot be reached) In the case of an emergency, the parents / guardians will always be the first persons we try to contact. However, in the case that we are unable to contact the parents / guardians, we need to have some other adult that we can call. Please include the information below of the contact person you choose in the case that we are unable to reach you.

Name(Required)

First Last

Relationship(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone(Required)

Cell Phone(Required)

Work Phone(Required)