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.
LA PREPARAZIONE ALL’INTERVENTO In preparazione all’intervento sono necessari alcuni esami per escludere qualsiasi controindicazione: glicemia, azotemia, creatininemia, bilirubinemia, prove complete di coagulazione (PT, PTT, FATTORE VIII), transaminasi, pseudocolinesterasi, emocromo con formula e conta piastrine, elettroliti ematici, esame completo urine, gruppo sanguigno