Faith Formation Registration Form

AOD Medical Treatment Release Form

Required on file for all students

Permission for medical treatmentBy checking this box as parent/guardian, I do hereby authorize the treatment of a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.YES

Minor

Name of Minor

Relationship to you

Reason for which release is intended:

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

Address of Minor

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Emergency Phone

Alternate Phone

Physician Name

Physician Phone

Physician Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Health Insurance

Policy

Group

Contract

ConsentI further authorize the person who presents the minor to sign the Acknowledgment of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician. I acknowledge that it is my responsibility to submit a new form if any of the above information changes.YES

Date consent given electronically

Address

Office Hours

Phone

Address

Office Hours

Phone

Address

Office Hours

Phone

Recent Posts

Recent Comments

Address

Office Hours

Phone

Email

ABOUT US

JOIN THE PARISH

GIVE

ARCHDIOCESE OF DETROIT

RESOURCES

SACRAMENTS

FAITH FORMATION

GET INVOLVED

Faith Formation Registration Form

Students Enrolling in Grades 1-8

Child(ren)'s Weekly Address & Number

Family Information

Additional Info

Recent Posts

Recent Comments