ST. MARY MAGDALEN PARISH CYO ARCHDIOCESE OF NEW ORLEANS MEDICAL INFORMATION AND CONSENT FORM GENERAL INSTRUCTIONS TO PARENTS/GUARDIANS: 1. Please take care in filling out this form. It provides crucial information for caregivers in the event of illness or medical emergency. Accuracy and thoroughness are encouraged. 2. Sections I, II and V are mandatory. Sections III and IV provide you with treatment options in non-emergency situations. Participant’s name: Birth date: Sex: Parent/Guardian’s name Home address: (Street) (City/State) (Zip) Home phone: Cellular phone: Business phone: Other: MEDICAL MATTERS As the parent/legal guardian of the above named child, who is currently associated with St. Mary Magdalen Parish. I hereby authorize the SMM CYO Leaders or his/her assistants to carry out the wishes I have named (herein) in areas of emergency medical treatment and other cases of illness. This authorization inclusively extends from July 1, 2018 through June 30, 2019. I hereby warrant that, to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Signature: Today’s Date: SECTION II. EMERGENCY MEDICAL TREATMENT In the of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the numbers listed herein, contact: Name & relationship: Phone: Family doctor: Phone: Family Health Plan Carrier: Policy #: Signature: Date:
ST. MARY MAGDALEN PARISH CYO ARCHDIOCESE OF NEW ORLEANS MEDICAL INFORMATION AND CONSENT FORM GENERAL INSTRUCTIONS TO PARENTS/GUARDIANS: 1. Please take care in filling out this form. It provides crucial information for caregivers in the event of illness or medical emergency. Accuracy and thoroughness are encouraged. 2. Sections I, II and V are mandatory. Sections III and IV provide you with treatment options in non-emergency situations. Participant’s name: Birth date: Sex: Parent/Guardian’s name Home address: (Street) (City/State) (Zip) Home phone: Cellular phone: Business phone: Other: MEDICAL MATTERS As the parent/legal guardian of the above named child, who is currently associated with St. Mary Magdalen Parish. I hereby authorize the SMM CYO Leaders or his/her assistants to carry out the wishes I have named (herein) in areas of emergency medical treatment and other cases of illness. This authorization inclusively extends from July 1, 2018 through June 30, 2019. I hereby warrant that, to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. Signature: Today’s Date: SECTION II. EMERGENCY MEDICAL TREATMENT In the of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the numbers listed herein, contact: Name & relationship: Phone: Family doctor: Phone: Family Health Plan Carrier: Policy #: Signature: Date:
2018-19%20Membership_Medical.docx