MEDICAL TREATMENT RELEASE FORM

St. Francis of Assisi Parish

Youth Ministry Program 2007-2008

To Whom It May Concern:

     As a parent/legal guardian I do hereby authorize the treatment by a qualified and licensed

Medical Doctor in an emergency which, in the opinion of the attending physician, may

endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed.

This authority is granted only after a reasonable effort has been made to reach me.

Name of Minor__________________________Relationship to you_________________

Reason for which release is intended: Participation in St. Francis Youth Ministry Activities

Address of Minor:___________________________________Phone_________________

Emergency Phone_____________________

Family Physician:__________________________________Phone________________

Address_______________________________________City_____________________

List allergies, medication, contacts, or other pertinent comments:

____________________________________________________________________

Health Insurance Data:

Company____________________________________Policy #___________________

Group__________________________________Contact_______________________

This release form is completed and signed of my own free will with the sole purpose of

authorizing medical treatment under emergency circumstances in my absence.