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MEDICAL FORMS

Emergency Medical Authorization Form

Vacation Bible School (VBS) at Saint Ambrose Parish

Emergency Medical Authorization Form - VBS, JWJ, PSR, First Reconciliation & First Eucharist

Personal Information

Parent / Guardian Name *

Last Name

Address *

Child's Name *

Child's Birthday *

Child's Doctor Name *

Child's Doctor Phone *

Child's Dentist Name *

Child's Dentist Phone *

Hospital of Choice *

Hospital Phone *

Insurance Provider *

Insurance Provider Phone *

Child's DETAILED Medical/physical/emotional *

If no "NONE" if not applicable

Allergies or sensitivities to any food, drink, or materials that might be used during class *

If no "NONE" if not applicable

Activities in which your child(ren) may not participate *

If no "NONE" if not applicable

Emergency Contacts

Name of Emergency Contact 1 *

Relationship to Child *

Best Phone to Reach Emergency Contact 1 *

Name of Emergency Contact 2 *

Relationship to Child *

Best Phone to Reach Emergency Contact 2 *

Consent

GRANT CONSENT: In the event that medical services cannot be delivered to me at the time, I hereby have been authorized to obtain a medical card given my consent for the administration of any treatment, diagnostic procedures, or surgery which in the judgment of the on-site physician, is deemed necessary. I have read all information on both sides of this form. I am aware that this is a release of liability to administer certain medical procedures, and sign it of my own free will.

of any treatment deemed necessary to the above medical professional, or in the event the designated physician is not available, by another licensed medical professional. Saint Ambrose Catholic Parish is not the holder of this child's Immunization and any release in any hospital or medical facility. The authorized physician here does not have copies of the medical statement of this child. I am responsible for any financial costs for emergency medical care obtained by my child.

REFUSING CONSENT: I do not give my consent for emergency medical treatment of my child. In the event of illness or emergency treatment being required, I will be called and may make my own arrangement.

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Photo Release and Authorization

Photo Release and Authorization *

Yes

I grant (and as a guardian of any minor children I shall not exclude) the Parish, publication, distribution, and sale or reproduction of any of all of photographs/images, negatives, and prints and all other matter/medium depicting Fr. St. Ambrose and the party specifically for such purposes as an expression of Faith/Service/Love, logos (i.e., expression, media content) or any other form of expression for print/audio/digital/video media.

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Stay updated on weekly news from Saint Ambrose Parish.

STAFF INFORMATION

Emergency Medical Form (Staff)

Please complete all fields below to the best of your knowledge. Your information will be kept privately on file.

If you have any questions or need to make changes, please contact Lynn Rogers at LRogers@stambrose.us

Personal Information

First Name

Last Name

Street Address

City

State

ZIP Code

Primary Phone

Alternate Phone

Date of Birth

Name of Hospitalization Plan

Insurance ID #

Do you have a Living Will?

Yes

Physician Information

Name of Primary Care Physician

Phone

Hospital of Practice

Please Note any information about your medical status of which medical personnel should be aware (i.e. any current medications, allergies, medical conditions, etc.):

Emergency Contact

First Name

Last Name

Primary Phone

Alternate Phone

I understand that this information shall be kept in the main office filing cabinet as directed by the Parish Administrator who will inform essential office personnel of its specific location. The emergency shall only be opened by First Responders or Medical Staff personnel, unless instructed by me or to do otherwise.

Emergency Medical Authorization Form - Youth Ministry

Personal Information

Parent / Guardian Name *

Last Name

Parent/Guardian Email *

Parent / Guardian Phone *

Address *

Child's Name *

Child's Birthday *

Child's Doctor Name *

Child's Doctor Phone *

Child's Dentist Name *

Child's Dentist Phone *

Hospital of Choice *

Hospital Phone *

Insurance Provider *

Insurance Provider Phone *

Child's DETAILED Medical/physical/emotional *

If no "NONE" if not applicable

Allergies or sensitivities to any food, drink, or materials that might be used during class *

If no "NONE" if not applicable

Activities in which your child(ren) may not participate *

If no "NONE" if not applicable

Emergency Contacts

Name of Emergency Contact 1 *

Relationship to Child *

Best Phone to Reach Emergency Contact 1 *

Name of Emergency Contact 2 *

Relationship to Child *

Best Phone to Reach Emergency Contact 2 *

Consent

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Photo Release and Authorization

Photo Release and Authorization *

Yes

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Stay updated on weekly news from Saint Ambrose Parish.

FORM

Emergency Medical Authorization

The Emergency Medical Form is required for participation in all religious education programs at Saint Ambrose. When you register for PSR, JWJ, First Reconciliation & First Eucharist, or VBS, the following form must be completed.

Religious Education at Saint Ambrose Parish

Personal Information

Parent / Guardian Name *

Last Name

Parent/Guardian Email *

Parent / Guardian Phone *

Address *

Child's Name *

Child's Birthday *

Child's Doctor Name *

Child's Doctor Phone *

Child's Dentist Name *

Child's Dentist Phone *

Hospital of Choice *

Hospital Phone *

Insurance Provider *

Insurance Provider Phone *

Child's DETAILED Medical/physical/emotional *

Enter "NONE" if not applicable

Allergies or sensitivities to any food, drink, or materials that might be used during class *

Enter "NONE" if not applicable

Activities in which your child(ren) may not participate *

Enter "NONE" if not applicable

Emergency Contacts

Name of Emergency Contact 1 *

Relationship to Child *

Best Phone to Reach Emergency Contact 1 *

Name of Emergency Contact 2 *

Relationship to Child *

Best Phone to Reach Emergency Contact 2 *

Consent

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Photo Release and Authorization

You hereby grant (and as a parent/guardian of any minor children) to the Clergy, Deacons and parishes, publications, distribution, reproduction of any and all photographs/videos, negatives, and prints and all other media/mediums depicting Saint Ambrose and the parish. Specifically for such purposes as: print/audio/digital/video distribution, parish websites, publications, news outlets or any organization of St. Ambrose reports to an archdiocesan agency or organizational representative of St. Ambrose as described below:

of any and all photographs/videos and any digital duplicated on the Saint Ambrose Website/Parish St. Software reports to an archdiocesan agency or organizational representative of St. Ambrose as described below:

Photo Release and Authorization *

Yes

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Stay updated on weekly news from Saint Ambrose Parish.

FORM

Thank you for registering for Embark Summer Service Camp!

Please complete the Emergency Medical Authorization form below for each child registration. Your registration is not complete until this Emergency Medical Authorization Form is submitted.

If you would prefer a paper copy, please download the Emergency Medical Authorization form, and return it to Brandan Bizzi.

Please note – registrations submitted after May 30th are not guaranteed to receive their requested tee shirt size.

Download PDF Of Emergency Medical Authorization Form

Embark Summer Service Camp Registration Confirmation

Personal Information

Parent / Guardian Name *

Last Name

Parent/Guardian Email *

Parent / Guardian Phone *

Address *

Child's Name *

Child's Birthday *

Child's Doctor Name *

Child's Doctor Phone *

Child's Dentist Name *

Child's Dentist Phone *

Hospital of Choice *

Hospital Phone *

Insurance Provider *

Insurance Provider Phone *

Child's DETAILED Medical/physical/emotional needs/concerns *

Enter "NONE" if not applicable

Allergies or sensitivities to any food, drink, or materials that might be used during class *

Enter "NONE" if not applicable

Activities in which your child(ren) may not participate *

Enter "NONE" if not applicable

Emergency Contacts

Name of Emergency Contact 1 *

Relationship to Child *

Best Phone to Reach Emergency Contact 1 *

Name of Emergency Contact 2 *

Relationship to Child *

Best Phone to Reach Emergency Contact 2 *

Consent

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Photo Release and Authorization

Photo Release and Authorization *

Yes

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Stay updated on weekly news from Saint Ambrose Parish.

Ablaze Emergency Medical Authorization Form

Personal Information

Parent / Guardian Name *

Last Name

Parent/Guardian Email *

Parent / Guardian Phone *

Address *

Child's Name *

Child's Birthday *

Child's Doctor Name *

Child's Doctor Phone *

Child's Dentist Name *

Child's Dentist Phone *

Hospital of Choice *

Hospital Phone *

Insurance Provider *

Insurance Provider Phone *

Child's DETAILED Medical/physical/emotional needs/concerns *

Enter "NONE" if not applicable

Allergies or sensitivities to any food, drink, or materials that might be used during class *

Enter "NONE" if not applicable

Activities in which your child(ren) may not participate *

Enter "NONE" if not applicable

Emergency Contacts

Name of Emergency Contact 1 *

Relationship to Child *

Best Phone to Reach Emergency Contact 1 *

Name of Emergency Contact 2 *

Relationship to Child *

Best Phone to Reach Emergency Contact 2 *

Consent

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Photo Release and Authorization

Photo Release and Authorization *

Yes

Please type your NAME and DATE *

By typing your name you are signing authorization form.

Stay updated on weekly news from Saint Ambrose Parish.