Holy Family Catholic Parishes

I/we the undersigned parent, parents or legal guardians , do hereby consent and authorized the administration of first aid to the minor(s) listed below, by the people in charge of the Holy Family Religious Education Program as their judgment deems necessary, and to make necessary referrals to a licensed medical professional for treatment of illness or accidents of a more serious nature. I understand that every effort will be made to contact me in the event I cannot be reached, I hereby give permission to the medical professional selected by the adult staff to hospitalize, secure proper treatment for, and to order injections, anethesia or surgery, if deemed necessary for the child(ren) named below.

In the event of any emergencies/need during the event, the undersigned hereby grants authority to be exercised at the discretion of my child's responsible chaperone to dispense over -the-counter medication. Parent/Guardian Name:

Today's Date

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Father's Phone

Mother's Phone

Emergency Contact Name

Phone

Special medications, drugs or other allergies (food), blood type or pertinent medical information:

Insurance Company

Policy No.

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Holy Family Parish

Consent to Medical Treatment Form

Holy Family Parish

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