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Catechist Medical Release and Liability Form

- Faith Formation

Catechist Medical Release and Liability Form (21+)
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- 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 (Video/Photography) Please select this field.
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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