Adoration Social Registration

Adoration Social at Epihany

Participants Name

Grade Level

Date of Birth

Street Address (St., City, Zip Code)

Parent/Guardian Name

Cell Phone Number(s) of those that can be reached in case of emergency

Event/Location

Date/Time of event.

Transportation:

Provided by Church

Not Provided by Church

Method of Transportation

Inputting your name below is the signature for this online form. Please type your name, signing and agreeing to the above statement.

Date Signed

Participant's Name (typing is a form of signature for this online form).

Date Signed

Do you carry insurance at this time?

Insurance Carrier

Name of Insured

Insurance Policy Number

Medical Matters: I hereby warrant to the best of my knowledge, all the information provided is true and correct and I assume all responsibility for the health of my child. I understand it is my responsibility to update the Medical information and Consent Form if there are any changes to my child's health (Please, initial)

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital/clinic for emergency medical or surgical treatment (Please, initial)

Family Doctor

Family Doctor's phone number

Medications: I hereby Grant Permission for my child to be given the following provided medications. All medications must be well labeled. (Note: any/all prescriptions medications must be in original pharmacy container with young person's name on the prescription label. Non-prescription/over-the-counter medications must be in original container with young person's name on the container). I release and hold harmless Prince of Peace Catholic Church, the Diocese of Orlando and any other religious, employees, volunteers, agents and representatives from any injury or harm resulting from administering medication (Please, initial

Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency, are as follows

My son/daughter is allergic to the following medications: (Please list below)

My son/daughter is allergic to the following medications

My son/daughter has had an episode of the following or has been diagnosed with seizures, asthma, diabetic

My son/daughter has had allergic reactions to the following (foods, dyes, latex, etc.);

My son/daughter has had a medical surgery within the last six months and still under doctor's care?

My son/daughter has a medically prescribed diet (please explain);

My son/daughter has the following physical limitations:

Immunizations current and up to date? (click on the box below to type YES or NO

Date of last tetanus/diphtheria immunization?

You should also be aware of these special medical conditions of my child:

Insurance carrier

Name of insured

Insurance Policy number

I fully understand the forgoing statements and sign and date (by typing my name and date below) this medical information & consent form knowingly, freely, and willlingly

386-672-5272

600 S. Nova Road
Ormond Beach, FL 32174

Adoration Social at Epihany

Contact Us

Quick Links

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386-672-5272

600 S. Nova RoadOrmond Beach, FL 32174

Adoration Social at Epihany

Contact Us

Quick Links

Connect with us

600 S. Nova Road
Ormond Beach, FL 32174