2022/23 St. Gabriel Youth Ministry Information Form

In order to attend any Youth Ministry events for the 2022/23 year, please complete this information form. Our various Events throughout the year will be detailed by various Sign Up Genius, flyers and emails If you have questions, please contact Samantha Coffman, at scoffman@st-gabriel.org.

Page 1 of 8 - Untitled Page

13%
General Information
Student's Name Student's Name * First Last
Student' #1 Phone Student' #1 Phone * - ### - ### ####
Student #1 - Can we text you? (If under 18 years old, we will group text you & your parents) *

Student #1 - Can we text you? (If under 18 years old, we will group text you & your parents) Yes No
Student #1 Email *
Student #1 School
Student #1 Grade in 2022/23 school year

Student #1 Grade in 2022/23 school year 6th 7th 8th 9th 10th 11th 12th
Student 1's Date of Birth Student 1's Date of Birth / MM / DD YYYY
Emergency Medical Authorization Form for Student 1

To enable parents/guardians to authorize the provision of emergency treatment for children who become ill or injured under parish/school authority, when parents/guardians cannot be reached.
Physician~Student 1 Physician~Student 1 * First Last
Physician's Phone Number~Student 1 Physician's Phone Number~Student 1 * - ### - ### ####
Dentist~ Student 1 Dentist~ Student 1 * First Last
Dentist's Phone Number~ Student 1 Dentist's Phone Number~ Student 1 * - ### - ### ####
Local Hospital to Transport Student 1 *
Facts concerning Student 1's medical history including allergies, food allergies, medication taken, chronic conditions (e.g. epilepsy, diabetes)
and any physical impairments of which a physician should be alerted: *

This information is extremely important in a medical emergency. If there are no medical concerns please type "NONE"
2022/23 Year
In the event reasonable attempts to contact me at the number listed below have been unsuccessful, I hereby authorize any of the staff, employees, volunteers, agents and/or representatives of the parish to provide for, seek, and authorize medical treatment for my child in the case of illness or accident from the closest and most appropriate licensed medical practitioner or hospital available. I understand that this authorization does not cover major surgery unless the medical opinions of two licensed physicians/dentists concurring in the necessity for such surgery are obtained for the performance of such surgery. *
2022/23 Year
If you refused to grant consent please answer the following. In the event of illness or injury requiring medical treatment, I wish the parish/school authorities to take the following action for
Student 1:
Responsibility to Carry Appropriate Medical Insurance - Student No. 1
I understand that it is my responsibility to carry appropriate medical insurance for my child and that such is not the responsibility of any other person or party, including, without limitation, the Parish or the Diocese of Cleveland.
Medical Insurance Co.
Policy Number
Member's Name
Member's Birth date Member's Birth date / MM / DD YYYY
I have read, understand, and agree to the foregoing provision. *

I have read, understand, and agree to the foregoing provision.
Parent or Legal Guardian for Student No. 1
By signing below, I represent and warrant that I am the parent or legal guardian of the above listed child and have the authority to execute this Agreement on his/her or their behalf and to act on his/her or their behalf.
Type your name in this box *
I am the child's: *
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

2022/23 St. Gabriel Youth Ministry Information Form

2022/23 St. Gabriel Youth Ministry Information Form

Page 1 of 8 - Untitled Page

General Information

Emergency Medical Authorization Form for Student 1