Freshman

BEFORE YOU COMPLETE THIS FORM.
This form only needs to be completed once yearly. If you have filled
out this form in the last 12 months, you need not fill it out again.
ST. THOMAS AQUINAS PERMISSION SLIP/EMERGENCY RELEASE FORM

Youth’s Name:_________________________ Grade_______ DOB______/______/______ M / F
Address_______________________________ City______________ State _____ Zip_________
Parent (s)/Guardian Name _______________________________________
Home Phone (_____)______________ Work Phone (_____)______________ Other (_____)______________
Physician’s Name______________________________________________ Phone (_____)_______________
Insurance Company_________________________________________ Member SS #_______-_____-_______
Policy # (if different ____________________ Group #____________________ Phone (_____)_____________
Pertinent Medical Information (including drug allergies, chronic conditions, current medications, other)
_________________________________________________________________________________________
PERMISSION TO TRAVEL AND PARTICIPATE / LIABILITY RELEASE:
I/We, _______________________________________the parent (s)/guardians of _______________________,
a minor, do hereby give him/her permission to travel with the youth group of St. Thomas Aquinas Catholic
Church and to participate in all youth activities and functions. We understand that our child may be traveling via
public or private transportation (for example: car, bus, boat, van, plane). We hereby recognize the inherent risk
associated with the various youth activities and forms of travel, and agree to save and hold harmless St.
Thomas Aquinas Catholic Church, the Roman Catholic Diocese of Dallas, and their employees, volunteers, and
agents from any liability or expense that may arise from my child’s participation in youth events and any travel
related incidents going to and from such event.
*Signature of Parent/Guardian________________________________________ Date ______/______/______
*Signature of Parent/Guardian________________________________________ Date ______/______/______
PERMISSION TO DISPENSE OVER THE COUNTER MEDS AND FIRST AID:
I/We, ____________________________________the parent (s)/guardians of __________________________,
a minor, do hereby give my son/daughter permission to take the following “over the counter” medications as
needed for minor aches and pains, under the supervision of church personnel. (Circle any and all that apply)
Imodium
*Signature of Parent/Guardian_________________________________________ Date ______/______/______
*Signature of Parent/Guardian_________________________________________ Date ______/______/______
AUTHORIZATION OF CONSENT TO TREAT MINOR: I/We, ____________________________________the
parent (s)/guardians of _____________________________, a minor, do hereby authorize St. Thomas Aquinas
Catholic Church, youth ministry leaders, servants, employees, officers and adult volunteers as agent(s) for the
undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and
hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of
any physician or surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or
treatment is rendered at the office of said physician or at a hospital.
It is understood that this authorization is given in advance of any specific treatment or diagnosis, but is given to
provide authority and power of treatment, or hospital care which the aforementioned physician in the exercise of
best judgment may deem advisable. This authorization is given pursuant to the provisions of Chapter 32 of the
Texas Family Code. This authorization shall remain effective for up to one year from the date of completion of
this form, unless sooner revoked in writing delivered to said agent(s).
RELEASE OF LIABITLITY: _________________________(Parent’s name) shal indemnify, hold free and
harmless, assume liability for, and defend St. Thomas Aquinas Catholic Church, its agents, servants,
employees, officers, and directors from any and all costs and expenses including but not limited to, medical
fees, attorney’s fees, discovery costs, court costs, and all other sums associated with any claim or action
founded thereon, including those arising or alleged to have arisen out of treatment of aforementioned minor. We
also release St. Thomas Aquinas Catholic Church, the Dallas Catholic Diocese, and any agents of the church of
any liability incurred due to aforementioned minor’s use of real or personal property belonging to St. Thomas
Aquinas Catholic Church, its agents, employees, or volunteers.
*Signature of Parent/Guardian_________________________________________ Date ______/______/______
Witness___________________________________________
This document will remain in effect for one year after date of signature.

Source: http://www.stthomasaquinas.org/library/STA-Youth-2013-Emergency-Release-Form.pdf