Microsoft word - medical_release_minor_revised_2008[1].doc

Family Name____________________
Date Form Completed____________
CPLC PERMISSION SLIP/EMERGENCY RELEASE FORM
Youth’s Name:___________________________________ Grade______________ DOB__________
Male/Female_______ Address___________________________City__________St/Zip__________
School_________________Parent (s)/Guardian Name_____________________________________
Home Phone___________________
Work Phone__________________ Other___________

Physician’s Name______________________________ Phone____________
Hospitalization Company___________________________ Member SS #_____________________
Policy # (if different)___________ Group #_________________ Phone #____________________
Pertinent Medical Information (including drug allergies, chronic conditions, current medications, other)
__________________________________________________________________
IN CASE OF EMERGENCY, PLEASE CONTACT ONE OF THE FOLLOWING PERSONS:
Name:________________________ Relationship: ________________ Phone:__________________
Name:________________________ Relationship: ________________ Phone:__________________
Name:________________________ Relationship: ________________ Phone:__________________
PERMISSION TO TRAVEL AND PARTICIPATE / LIABILITY RELEASE:

I/We, ________________________________the parent (s)/guardians of _____________________,
a minor, do hereby give him/her permission to travel with the youth group of Catholic Pro-Life
Committee and to participate in all youth activities and functions. We understand that our child may be
traveling via public or private transportation (for example: car, bus, boat, van, plane). We hereby
recognize the inherent risk associated with the various youth activities and forms of travel, and agree to
save and hold harmless Catholic Pro-Life Committee and their employees, volunteers, and agents from
any liability or expense that may arise from my child’s participation in youth events and any travel related
incidents going to and from such event.
*Signature of Parent/Guardian__________________________________ Date________________
*Signature of Parent/Guardian__________________________________ Date________________
PERMISSION TO DISPENSE OVER THE COUNTER MEDS AND FIRST AID:

I/We, _____________________________the parent (s)/guardians of _______________________,
a minor, do hereby give my son/daughter permission to take the following “over the counter” medications
as needed for minor aches and pains, under the supervision of church personnel.
Circle any and all that apply
--Immodium

*Parent/Guardian Signature__________________________________ Date_______________
*Parent/Guardian Signature__________________________________ Date_______________

Permission Slip and Medical Release for Minor AUTHORIZATION OF CONSENT TO TREAT MINOR:

I/We, ______________________________the parent (s)/guardians of ______________________,
a minor, do hereby authorize Catholic Pro-Life Committee youth ministry leaders, servants, employees,
officers and adult volunteers as agent(s) for the undersigned to consent to any x-ray examination,
anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by,
and is to be rendered under the general or specific supervision of any physician or surgeon licensed under
the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of
said physician or at a hospital.
It is understood that this authorization is given in advance of any specific treatment or diagnosis, but is
given to provide authority and power of treatment, or hospital care which the aforementioned physician in
the exercise of best judgment may deem advisable.
This authorization is given pursuant to the provisions of Chapter 32 of the Texas Family Code. This
authorization shall remain effective for up to one year from the date of completion of this form, unless
sooner revoked in writing delivered to said agent(s).
Release of Liability:
_________________________(Parent’s name) shall indemnify, hold free and harmless, assume liability
for, and defend Catholic Pro-Life Committee, its agents, servants, employees, officers, and directors from
any and all costs and expenses including but not limited to, medical fees, attorney’s fees, discovery costs,
court costs, and all other sums associated with any claim or action founded thereon, including those
arising or alleged to have arisen out of treatment of aforementioned minor. We also release Catholic Pro-
Life and any agents of the committee of any liability incurred due to aforementioned minor’s use of real
or personal property belonging to Catholic Pro-Life Committee its agents, employees, or volunteers.

Media Release:

We also release for ourselves (and or children) all rights and claims to all photographic images and video
or audio recordings of ourselves or our children.


___________________________________________
Parent/Legal Guardian’s Signature
___________________________________________
Parent/Legal Guardian’s Printed Name

SUBSCRIBED AND SWORN TO BEFORE ME, this _______ day of _________, 20__.
___________________________________
Notary Public
Permission Slip and Medical Release for Minor

Source: https://www.prolifedallas.org/files/Medical_Release_Minor_YFL.pdf