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Emergency Contact and Disaster Release Form

- Religious Education

Emergency Information Form / Forma de Información para Emergencias
The maximum number of form submissions has been reached. This form is currently not available.
- A separate form must be completed for each child.
  
  Esta forma debe de ser completada por cada hijo(a).
  
  Please Print / Por favor imprimir
- Child or Youth's full Name / Nombre complete del hijo(a): REQUIRED Please fill out this field. Please enter valid data.
- If a parent or guardian can’t be reached in an emergency, please contact:
  
  Si el padre, madre o guardian no pueden ser contactados en una emergencia, favor de contractar a.
- First and Last Name / Nombre completo REQUIRED Please fill out this field. Please enter valid data.
- Relationship to child or youth / Parentezco con el hijo(a) REQUIRED Please fill out this field. Please enter valid data.
- Emergency contact phone # / No. de teléfono de contacto para emergencias REQUIRED Please fill out this field. Please enter valid data.
- Name of Family Doctor / Nombre del médico familiar Please enter valid data.
- Phone # / No. de teléfono Please enter valid data.
- Name of Family Dentist / Nombre del dentista familiar Please enter valid data.
- Phone # / No. de teléfono Please enter valid data.
- Medical Insurance Carrier / Compañía aseguradora de salud Please enter valid data.
- Carrier Policy # / No. de póliza Please enter valid data.
- Group # / No. grupo Please enter valid data.
- Medical Insurance Address Information / Dirección de la compañía aseguradora de salud Please enter valid data.
- Phone # / No. de teléfono Please enter valid data.
- PARENT OR GUARDIAN SIGNATURE / Firma del Padre, Madre o Guardián
  
  By clicking I Agree, I understand that the parish does not assume responsibility for payment of physician. However, in an emergency the parish may choose a physician. In an emergency, I give the parish permission to have my child(ren) or youth receive medical treatment.
  
  Al hacer clic estoy de acuerdo, entiendo que la parroquia no asume responsabilidad financiera por los servicios de un(a) doctor(a). Sin embargo, en una emergencia, doy permiso a la parroquia para que seleccione a un doctor(a). En caso de emergencia, doy permiso para que la parroquia obtenga tratamiento médico para mi(s) hijo(s) o hija(s).
- I AGREE & GIVE MY PERMISSION Please select this field.
- Signature / Firma REQUIRED Please fill out this field. Please enter valid data.
- Email Please enter an email address.
- Date REQUIRED Please fill out this field. Please enter a date.
- Given the nature of the program, does your child or youth have any physical, mental, emotional, cognitive, or other limitations or restrictions that would require the parish to make a minor adjustment to enable your child or youth t0 participate?
  
  Dada la naturaleza de este programa, tiene su hijo(a) alguna limitación física, mental, emocional, de prendizaje, o alguna restricción por la que la cual la parroquia debe hacer pequeños ajustes que permitan a su hijo(a) participar?
- Yes / No REQUIRED Yes / Si No (if No, please place an N/A, not applicable on the Restriction space below) Please fill out this field.
- If “yes”, what type of restriction does your child or youth have or what adjustment(s) will be needed?
  
  Si responde “sí”, que tipo de restricciones tiene su hijo(a) y que tipo de cambios o ajustes se necesitan hacer?
- Restrictions REQUIRED Please fill out this field.
- List any medical condition which restricts physical activity or requires special attention or minor adjustments. Include conditions such as asthma or allergies (e.g. peanuts, bee stings, etc.)
  
  If none, please indicate “none”.
  
  Enumere cualquier condición médica que restrinja la actividad física o requiera atención especial o algún tipo de ajuste menor. Incluya afecciones como el asma o alergias (por ejemplo: al maní, las picaduras de abejas, etc.)
  Si no hay ninguna, sírvase indicar "ninguna”.
- List medical conditions REQUIRED Please fill out this field.
- Does your child or youth take any medications?
  
  ¿Está su hijo(a) tomando algún medicamento?
- Yes / No REQUIRED Yes / Si No (If NO, please place N/A not applicable on the space below) Please fill out this field.
- If “yes”, please provide a list. / Si responde “sí”, provea una lista de medicamentos.
- EARTHQUAKE OR DISASTER RELEASE INFORMATION
  Información sobre el paradero de su hijo(a) en caso de emergencia o terremoto
  
  This section will be completed for each child or youth by a parish staff or leader, in the event of an earthquake or other disaster.
  
  Esta seccion debe ser completada para cada hijo(a) por una persona que es empleada o líder en la parroquia, en casa de un terremoto u otro desastre.
- Name of Child or Youth REQUIRED Please fill out this field. Please enter valid data.
- Person Released to: Please enter valid data.
- Signature whom child was released to Please enter valid data.
- Date Please enter a date.
- Time: Please enter valid data.
- Location to where the child(ren) or youth was taken: / Lugar a donde fue llevado su hijo(a):
- Parish staff or leader releasing the child: / Empleado o líder parroquial que entregó a su hijo(a):
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Emergency Contact and Disaster Release Form

Emergency Information Form / Forma de Información para Emergencias

A separate form must be completed for each child.

Please Print / Por favor imprimir

PARENT OR GUARDIAN SIGNATURE / Firma del Padre, Madre o Guardián

By clicking I Agree, I understand that the parish does not assume responsibility for payment of physician. However, in an emergency the parish may choose a physician. In an emergency, I give the parish permission to have my child(ren) or youth receive medical treatment.

Given the nature of the program, does your child or youth have any physical, mental, emotional, cognitive, or other limitations or restrictions that would require the parish to make a minor adjustment to enable your child or youth t0 participate?

If “yes”, what type of restriction does your child or youth have or what adjustment(s) will be needed?

List any medical condition which restricts physical activity or requires special attention or minor adjustments. Include conditions such as asthma or allergies (e.g. peanuts, bee stings, etc.)

If none, please indicate “none”.

Does your child or youth take any medications?

EARTHQUAKE OR DISASTER RELEASE INFORMATION
Información sobre el paradero de su hijo(a) en caso de emergencia o terremoto

Emergency Contact and Disaster Release Form

A separate form must be completed for each child.

Please Print / Por favor imprimir

PARENT OR GUARDIAN SIGNATURE / Firma del Padre, Madre o Guardián

By clicking I Agree, I understand that the parish does not assume responsibility for payment of physician. However, in an emergency the parish may choose a physician. In an emergency, I give the parish permission to have my child(ren) or youth receive medical treatment.

Given the nature of the program, does your child or youth have any physical, mental, emotional, cognitive, or other limitations or restrictions that would require the parish to make a minor adjustment to enable your child or youth t0 participate?

If “yes”, what type of restriction does your child or youth have or what adjustment(s) will be needed?

List any medical condition which restricts physical activity or requires special attention or minor adjustments. Include conditions such as asthma or allergies (e.g. peanuts, bee stings, etc.) If none, please indicate “none”.

Does your child or youth take any medications?

EARTHQUAKE OR DISASTER RELEASE INFORMATION Información sobre el paradero de su hijo(a) en caso de emergencia o terremoto

List any medical condition which restricts physical activity or requires special attention or minor adjustments. Include conditions such as asthma or allergies (e.g. peanuts, bee stings, etc.)

If none, please indicate “none”.

EARTHQUAKE OR DISASTER RELEASE INFORMATION
Información sobre el paradero de su hijo(a) en caso de emergencia o terremoto