Legal - Medical Forms

* indicates a required answer.

This form must be electronically signed to complete registration.

The electronically signed, being the parent(s) or legal guardian of the following children:

1.
*

1st Child's Full Legal Name (First Middle Last)

2.
*

1st Child's Date of Birth (MM/DD/YYYY)

3.

2nd Child's Full Legal Name (First Middle Last)

4.

2nd Child's Date of Birth (MM/DD/YYYY)

5.

3rd Child's Full Legal Name (First Middle Last)

6.

3rd Child's Date of Birth (MM/DD/YYYY)

7.

4th Child's Full Legal Name (First Middle Last)

8.

4th Child's Date of Birth (MM/DD/YYYY)

9.

5th Child's Full Legal Name (First Middle Last)

10.

5th Child's Date of Birth (MM/DD/YYYY)


 

LEGAL WAIVER

I agree prior to participating, I and the minor participant (student), will inspect the facilities and equipment to be used. If I believe anything is unsafe, I will immediately advise the administrators of such conditions.

I acknowledge and fully understand that each participant will be engaged in activities that involve risk of injury which might result not only from their own actions, inactions or negligence, but the actions, inactions or negligence of others, the rules of conduct, or conditions of the premises or any of the equipment used. Further, that there may be risks not known to us or foreseeable at the time.

I assume all foregoing risk and accept personal responsibility for the damages following such injury.

I, intending to be legally bound, do hereby release, waive, discharge and consent not to sue WEST’s administrators, board, employees, tutors or volunteers of the organization, other participants and St. Michael Catholic Church, all which are herein after referred to as “releases” from any and all liability to each the undersigned, his or hers and next of kin for any claims, demands, losses or damages, on account of injury including death or damage to property, caused or alleged to cause in whole or part by negligence to the release of otherwise in connection with association or entry and/or arising in participation in activities led by WEST.

I hereby release all members of WEST of any and all liability resulting from medical treatment. I understand if medical attention is necessary and I am not present, WEST has my permission to call an ambulance to transport any family member I have listed above to the nearest medical facility for emergency medical treatment. I am responsible for all expenses incurred.

THE ELECTRONICALLY SIGNED HAS READ THE ABOVE WAIVER AND RELEASE, AND UNDERSTANDS THAT HE/SHE HAS GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGNS IT VOLUNTARILY.

11.
*

Parent / Guardian's Full Name (First Last)

12.
*

Today's Date


 

MEDICAL RELEASE

I (we) request and authorize any physician, associates, assistants, agents and employees thereof, to provide any x-ray, examinations, anesthetic, diagnosis, medical, or surgical treatment, or hospital or clinic service that may be required by said minor in the estimation of such physician, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis or required treatment and is given to encourage said hospital and said physicians to exercise their best judgment as to the requirements of such diagnosis and treatment in those instances when a parent of the minor is unavailable to provide the necessary consent to treatment.

13.
*

Parent / Guardian's Full Name (First Last)

14.
*

Today's Date

15.
*

Parent / Guardian's Phone Number with Area Code

Please provide the following Health information: Person(s) to contact in case of non-medical emergency when you are not available:

16.
*

Emergency Contact Name

17.
*

Emergency Contact Phone 1

18.

Emergency Contact Phone 2

19.
*

Health Insurance Company

20.
*

Health Insurance Contract Number

21.
*

Health Insurance Group Number

22.

Please describe any medical/general information that would be helpful in the care of your child:

23.

Please list any medications and/or allergies that your child may need/has:

24.

Please list any additional medical concerns: