ST. ANNE/SACRED HEART/ST. VALENTINE MEDICAL TREATMENT RELEASE FORM

TO WHOM IT MAY CONCERN:

As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed Medical Doctor in an emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Name of Minor: D-O-B:

Relationship: Reason for which release is intended:

This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Dated: Parent/Guardian Signature:

Address of Minor:

Phone: ( ) Emergency Phone: ( )

Family Physician: Phone:

Address/City/Zip:

Are there any physical restrictions/limitations or medical conditions (e.g. asthma, allergies, epilepsy) of which we should be aware?

Yes No If yes, please describe:

HEALTH INSURANCE DATA:

Company:

Policy: Group: Contract:

I herby request and authorize Youth Ministry supervisors to administer my child’s prescribed medication as directed by our doctor.

Administration of medication to participant liability: As school administrator, teacher, or other school employee designated by the school administrator, who in good faith administers medication to a pupil (participant) in the presence of another adult pursuant to written permission of the pupil’s parent or guardian and in compliance with the instructions of a physician is not liable in a criminal action or for civil damages as a result of the administration except for an act of omission amounting to gross negligence or willful and wanton misconduct. (Michigan Compiled laws, 1982 {380.1178}

Parent/Guardian Signature:

MEDIA RELEASE FORM

The Youth Ministry Programs will not photograph, videotape and/or voice tape individuals in its program without consent. This form allows you to give permission for your child to be photographed, videotapes and/or voice tapes by Youth Ministry personnel and/or area news reporters. Photographs, videotapes and/or voice tapes, when consented to, will only be used for the purposes you specify below.

I, , herby give permission for personnel of the Youth Ministry programs to photograph, videotape and/or voice tape my child (or allow area news reporters to do the same) for purposes of: (circle items that you will allow)

1. Public information for promotion of the Youth Ministry Programs

2. St. Anne/Sacred Heart/St. Valentine Youth Ministry Programs only

-or-

_____Please do not photograph, videotape and/or voice tape my child.

Parent/Guardian Signature: Date:

Child’s Name