Parental Permission Form

Event_________________________Date(s) ______ _______________________________

Name of Participant___________________________ Male_____ Female_______

Address___________________________________________________________

Town______________________________________State________Zip________

Date of Birth_______________________________________

Insurance Information

Family Health Insurance Co.___________________ Policy #________________

Family Physician_____________________________ Phone # ______________

Medication(s)_________________________________ Allergies_____________

Any other information we may need to know:

Parental Release

In signing this form, I hereby certify that the above information is correct and give permission for my child to be transported to and from this activity. I give permission for the release of medical records to an attending physician in case of injury or illness.

In the case of medical emergency, I understand that every effort will be made to contact the parent(s) or guardian of my child. In the event I cannot be reached, I hereby give permission to the physician attending my child to hospitalize, secure proper and necessary treatment for my son/daughter, as named herein.

I hereby agree that no liability is assumed by the Archdiocese of Boston or Saint Zepherin Parish for the claims which may arise out of this activity.

Signature of Parent or Guardian_______________________________________

Date_____________ Home Phone ______________Work Phone _____________

In emergency call_____________________________ Phone________________