Facebook Instagram YouTube

Catechist Medical Release and Liability Form

- Parish Life

Catechist Medical Release and Liability Form (21+)
The maximum number of form submissions has been reached. This form is currently not available.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Email REQUIRED Please fill out this field. Please enter an email address.
- Ministry REQUIRED Please fill out this field.
- Address / City / Zip REQUIRED Please fill out this field. Please enter valid data.
- Home Phone REQUIRED Please fill out this field. Please enter valid data.
- Work Phone REQUIRED Please fill out this field. Please enter valid data.
- Physician's Name REQUIRED Please fill out this field. Please enter valid data.
- Physician's Phone REQUIRED Please fill out this field. Please enter valid data.
- The following request is pertinent information if you are rendered unconscious
- Date of Birth, including Year Please enter valid data.
- Age REQUIRED Please fill out this field. Please enter valid data.
- Date of last Tetanus shot REQUIRED Please fill out this field. Please enter valid data.
- Please list ALL medical conditions REQUIRED Please fill out this field.
- Please list ANY medications (prescription or non-prescription) you would like us to be aware of REQUIRED Please fill out this field.
- Do you have medical insurance? REQUIRED Yes No Please fill out this field.
- If Yes, please provide the following information:
- Insurance Company Please enter valid data.
- Policy in the name of Please enter valid data.
- Policy number Please enter valid data.
- Name of Emergency Contact Please enter valid data.
- Phone number Please enter valid data.
- In the event the participant does not have insurance, payment in full for medical care becomes the responsibility of the patient.
  I Agree Please select this field.
- In signing the line above I agree to abide by any/all policies and rules established for this event/activity (see Code of Conduct). Should I not be able to maintain the guidelines and expectations of the adult chaperones/young adult assistants, I understand that there will be consequences for my actions, which could include being asked to leave the event.
  I Agree Please select this field.
- Video/Photography Consent (Adult)
  
  As an adult, I understand that promotional pictures and videos (individual and group) will be taken during this event. I give permission for my picture to be uesd for promotional materials (newsletter, web page, calendars, Power Point, video etc.) highlighting the event.
  I Agree Please select this field.
Submit

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Catechist Medical Release and Liability Form

Catechist Medical Release and Liability Form (21+)

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston

Office Hours

Catechist Medical Release and Liability Form

St. Bernadette Catholic Church Archdiocese of Galveston-Houston

Office Hours

St. Bernadette Catholic Church
Archdiocese of Galveston-Houston