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St. Anthony Catholic Church ~ Permission, Health and Medical Release Form
Date/Activity/Destination: October 23-24-Confirmation Retreat at Creighton University Retreat Center in Griswold, Iowa
Departure Place/Time: Friday, October 23 at 5:00 p.m. from church parking lot
Return Place/Time: Saturday, October 24 at 12:00 midnight to church parking lot
Supervisor of Activity: Laura Hollinrake
Volunteer chaperone(s): Laura Hollinrake plus others to be determined based on registration numbers.
Method of Transportation: Personal automobiles.
Student Cost: $0
Indicates required field
Participant Birthdate (mm/dd/yyyy)
Parent/Guardian Phone (include area code)
Emergency Contact (other than parent/guardian)
Emergency Contact Phone (include area code)
Name of Health Insurance Company
Policy and Group Numbers
Please describe any important health information regarding your child (e.g. allergies, asthma, medications, chronic conditions, physical limitations)
Statement of Consent:
By completing and submitting this form,
I give permission for my child/legal dependent to participate in the above mentioned activity, sponsored by
St. Anthony Catholic Church.
In the event of sickness or accident, the adults supervising this activity have my permission to secure medical care for my child/legal dependent. I hereby
release St. Anthony’s
and adult chaperones from any and all claims arising out of or from any accident or other occurrence, causing injury to any person or property, during this event.
In the event of an emergency,
I hereby give permission to the physician selected by the adult/s supervising this activity to secure proper and adequate treatment including hospitalization, injection, anesthesia or surgery for myself, if of majority age, or the child/legal dependent listed, if a minor. I accept responsibility for all medical/surgical treatment charges, which may be incurred.
Authorization for Use of Child’s Name, Likeness, and/or Photographic Image:
I grant permission to St. Anthony Catholic Church to use my child’s name, likeness, and/or photographic image in the production of parish or diocesan newsletters, bulletins, websites, posters, bulletin boards, slide shows and other parish or diocesan promotional materials and in articles about the parish that may be published in local or diocesan newspapers. I further understand that St. Anthony’s is not responsible for access to the Internet information or downloads made by users using the web prior to removal of web references and that my child’s name, likeness or image may continue to be used in any publication already printed or published prior to removal by St. Anthony’s.