Health History for Religious Education

- Ministries

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- I understand that by submitting this form electronically, my typed full name, acts as my signature.
- Participants Name REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Male Female Please fill out this field.
- Birth Date REQUIRED Please fill out this field. Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
- Parent/Guardian REQUIRED Please fill out this field. Please enter valid data.
- Relationship REQUIRED Please fill out this field. Please enter valid data.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Home Telephone Number REQUIRED Please fill out this field. Please enter valid data.
- Work Telephone Number REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Cell Phone Carrier Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- DISCLOSURE STATEMENT: My Child has no physical, medical, or other condition that will affect or be affected by participation in Religious Education Activites. Further, my child has no allergy that should be disclosed to emergency personnel.
- I agree, this child has no physical, medical or other condition Please enter valid data.
- DISCLOSURE STATEMENT: My child does have a physical, medical, or other condition that will affect or be affected by participation in Religious Education Activities. Or my child has an allergy that should be disclosed to emergency medical personnel.
  
  If your child does have a condition, provide a full explanation in the next box and type in your full name to act as your signature.
- My child DOES have physical, medical or other condition
- PERMISSION FOR DISCLOSURE AND EMERGENCY MEDICAL TREATMENT
  The parish has my permission, in an emergency when parents or guardians cannot be contacted, to take my child to a hospital emergency room. The hospital and its medical staff have my authorization to provide treatment that a physician deems necessary for the well-being of my child. I will be contacted as soon as possible and will be advised prior to any further treatment by the hospital or doctor. I understand and agree that I will be responsible for the emergency medical charges.
  
  I understand that by entering my full name, this acts as my signature.
- I AGREE REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter valid data.
- FAMILY INSURANCE PROVIDER/HEALTH PLAN Please enter valid data.
- HEALTH PLAN NUMBER Please enter valid data.
- In an emergency, when unable to reach a parent/guardian, contact:
- Emergency Contact 1 REQUIRED Please fill out this field. Please enter valid data.
- Contact 1 Phone Number REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact 2 REQUIRED Please fill out this field. Please enter valid data.
- Contact 2 Phone Number REQUIRED Please fill out this field. Please enter valid data.
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