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Youth Annual Emergency Medical Care Form

Note:   Parents must complete and submit this form prior to the commencement of each Parish Youth Ministry Program year for each child enrolled in a Parish Youth Ministry Program. Parents are responsible for updating the information on this form should changes occur during the Parish Youth Ministry Program year.

 

Consent to Emergency Medical Care
In the event of an emergency, I request that the parish make reasonable attempts to contact me at the numbers I have provided. I understand that in an emergency, exigent circumstances may prevent the parish from contacting me immediately, or the parish may be unable to reach me. I therefore consent to the parish taking action which it deems necessary to secure emergency medical care/treatment for my child even if I have not been contacted. I understand that decisions concerning the type of emergency medical care or treatment administered are normally made by health care providers and not by the parish and that exigent circumstances may require the administration of emergency medical care or treatment without my prior consent. However, I have indicated below any treatment preferences I have for my child which the parish may disclose to a health care provider.
Name of Youth
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Parish
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Youth's Grade
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Emergency Contact Name(s) and Phone Number(s)
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 In the event of an emergency, I request that the parish make reasonable attempts to contact any of the following people.
My preferred physician (with phone number) is:
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My preferred dentist (with phone number) is:
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My preferred hospital is:
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Special Circumstance
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 By typing my initials, I am requesting the parish have receipt of my consent prior to my child receiving major surgery unless the medical opinions of two licensed physicians or dentist, concurring in the necessity for such surgery, are obtained before surgery is performed. If you do not require this special provision prior to surgery, leave box blank.
Other Medical Preferences
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Insurance Company Name
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 By completing this section, I give permission for the following insurance information to be disclosed to a health care provider.
Insurance Policy/Group/Claim/#'s
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 By completing this section, I give permission for the following insurance information to be disclosed to a health care provider.
Allergies/Medical Information
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 By completing this section, I give permission for information pertaining to allergies, medications, etc to be disclosed to a health care provider.
Digital Signature
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 By typing my full name and today's date, I agree to the following: I understand that in the event of any emergency, the parish will make reasonable efforts to notify a health care provider of my choice, as indicated on this form, but I acknowledge that I am responsible for communicating such information to the appropriate medical personnel.
Photo Permission
Please type DO or DO NOT grant permission...with Digital Signature & Date
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 Please type DO or DO NOT grant permission, along with your full name & date to signify for acceptance or denial of the following: I DO GRANT permission for our parish and the Diocese of Fort Wayne-South Bend to use my child's image in any photograph, internet site, or visual media for promoting parish or diocesan youth ministry or for any other lawful purpose. -or- I DO NOT GRANT permission for our parish and the Diocese of Fort Wayne-South Bend to use my child's image.
Electronic Communication
During the youth ministry program year/school year the parish of St. Michael the Archangel will use the following forms of safe communication and technology to communicate with your minor child regarding various educational or programming events. *Parish website: www.stmichaelwaterloo.com *Remind.com (class code: 5ab3e) *Social networking site (private facebook group open only to YG families from St. Michael's): www.facebook.com/groups/stmikesyouthgroup *Online video streaming from appropriate ministry sites: lifeteen.com, ascensionpress.com, flipgrid.com, zoom meetings, etc.
Please type DO or DO NOT grant permission...with Digital Signature & Date
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 Please type DO or DO NOT grant permission, along with your full name & date to signify for acceptance or denial of the following: I DO GRANT permission for our parish to contact my youth via the means of electronic communication noted above. -or- I DO NOT GRANT permission for our parish to contact my youth via the means of electronic communication noted above.
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