Youth Participant’s Name
First
Last
Sex Parent/Guardian Name
First
Last
Home Address Texting Emergency Contact Name
First
Last
Other than parent/guardian
Texting
Insurance Information Is the participant insured? If yes, please fill out the information below from the youth participants Insurance Card:
Name of Policy Holder
First
Last
whose name is the policy in
Claim Address
Medications
Check All that Apply
Note: DO NOT CHECK ALL BOXES AS ONE MAY CANCEL OUT ANOTHERConsent This child takes no medication and will bring no medication with him/her.
Consent This child takes medication/s and will self-medicate.
The child will bring all such medications necessary, and such medications will be clearly labeled. I understand that the child will be required to turn all medication(s) over to a supervising adult designated to keep medication(s). I further understand that it will be this child’s responsibility to present himself/herself at a location designated for returning medication(s) to this child at the frequencies/times listed below. I understand that the adult to whom this child surrenders the medication has no medical training and this adult will not measure dosages. This child will return the medication(s) to the adult after he/she self-medicates. At the conclusion of the event it will be this child’s responsibility to pick up remaining medication(s), if any, at the self-medication designated location. Names of medications and exact dosage and frequencies/times are as listed below: (you may attach a sheet to this form if you need more space just make sure to sign and date it as well)
Consent This child takes medication but is unable to self-medicate.
The child’s parent/guardian/conservator will provide and dispense any and all needed medications.
Consent The child’s parent/guardian/conservator will provide and dispense any and all needed medications.
Consent No medication of any type.
Whether prescription or nonprescription may be administered to this child unless the situation is life-threatening and emergency treatment is required.
Over-The-Counter Medication Permission I grant permission for the following nonprescription medication to be given to this child in the recommended dosage on the medication bottle.
Non-aspirin pain reliever Throat Lozenge Decongestant Antacid Antihistamine
Specific Medical Information Allergic reactions (medications, foods, plants, insects, etc.)
Has child recently been exposed to contagious disease or condition such as mumps, measles, chicken pox, etc.? Please describe any other special medical or non-medical conditions of the child?
Release/Indemnification Information: PARENT/GUARDIAN grants permission for YOUTH PARTICIPANT to participate with the various programs and activities of the Diocese of Fort Worth and/or the PARISH beginning the 1st day of June, 2023 and continuing through the 30th day of June, 2024. These various programs and activities will take place under the guidance and direction of employees and/or volunteers from the PARISH and/or the Diocese of Fort Worth. This permission and liability waiver will be kept on file and will accompany the child on any and all programs and activities of the Diocese of Fort Worth and/or the PARISH. A separate FORM B Consent to Participate and Consent to Emergency Medical Treatment must be filled out and turned in to accompany this form per each program and/or activity. Promotional Release Social Media Release
To the best of my ability, everything I have stated here is true and accurately reflects my wishes. By checking this box and typing your name above, you have agreed that this is your electronic signature.
Name
First
Last
