Family name______________________________

Family Name______________________________ Date Form Completed_______________________ St. John Nepomucene – FALL 2011-Spring 2012 LIFETEEN PERMISSION SLIP/EMERGENCY RELEASE
FORM (Please Completely Answer ALL Questions)
Please Print as Clear as Possible. Youth’s Name:________________________________ School/Grade:_______________ DOB: ___/___/__ M / F (circle one) Address:__________________________________________ City:__________________ State:______ Zip:_________ Parent(s) / Guardian(s) Name(s):_______________________________________________________________________ Home #: (______)________________ Work #: (______)_________________ Cell #:(_____)____________________ Physician’s Name:______________________________________________ Phone #: (______)____________________ Insurance Company:_____________________________________________ Policy #:________________________ Group #:_____________________ Phone #: (______)____________________ Pertinent Medical Information (including drug allergies, chronic conditions, current medications, etc.): _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ PERMISSION TO TRAVEL AND PARTICIPATE

I / We _______________________________________________________, the parent(s) / guardian(s)
of _________________________________________, a minor, do hereby give him/her permission to travel
with the youth group of St. John Nepomucene Catholic Church and to participate in all youth activities and
functions. I / We understand that my/our child may be traveling via church/public transportation (example: bus, car,
boat, van, plane), and hereby recognize the inherent risk associated with the forms of travel.
Signature of Parent / Guardian:_______________________________________________ Date:_________________

Signature of Parent / Guardian:_______________________________________________ Date:_________________
PERMISSION TO DISPENSE OVER-THE-COUNTER MEDICATIONS AND FIRST AID
I / We _______________________________________________________, the parent(s) / guardian(s) of __________________________________, a minor, do hereby give him/her permission to take the following “over-the-counter” medications as needed for minor aches and pains, under the supervision of church personnel. (Circle all that apply):
Signature of Parent / Guardian:_______________________________________________ Date:_________________
Signature of Parent / Guardian:_______________________________________________ Date:_________________
AUTHORIZATION OF CONSENT TO TREAT MINOR
I / We _______________________________________________________, the parent(s) / guardian(s) of __________________________________, a minor, do hereby authorize St. John Nepomucene Catholic Church, youth ministry leaders, servants, employees, officers and adult volunteers, as agents 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 the advance of any specific treatment or diagnosis to provide authority and power to consent to 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 hear from the date of execution of this form, unless sooner
revoked in writing and delivered to St. John Nepomucene Catholic Church.
Signature of Parent / Guardian:_______________________________________________ Date:_________________
Signature of Parent / Guardian:_______________________________________________ Date:_________________
INDEMNITY AND RELEASE OF LIABILITY

I / We _______________________________________________________, the parent(s) / guardian(s)
of __________________________________, a minor, agree to indemnify, defend, release, and save and hold
harmless St. John Nepomucene Catholic Church and the Roman Catholic Diocese of Dallas, as well as their
employees, volunteers, agents, officers and directors, from any claim, action, liability, or expense that may arise
from my/our child’s participation in youth events, including but not limited to, those arising out of any medical
treatment of my/our child, any travel to and from youth events, and any use of real or personal property
belonging to St. John Nepomucene Catholic Church or the Roman Catholic Diocese of Dallas, regardless of
whether the claim, action, liability, or expense arises from any act, omission, or negligence, whether active or
passive, or sole or concurrent, of St. John Nepomucen Catholic Church, the Roman Catholic Diocese of Dallas, or
any of their employees, volunteers, agents, officers or directors.
Signature of Parent / Guardian:_______________________________________________ Date:_________________
Signature of Parent / Guardian:_______________________________________________ Date:_________________

Source: http://www.stjohncc.net/wp-content/uploads/2012/03/Permission-Slip.pdf