| Name: ___________________________________________ | Date of Birth: __________________ |
| Address: _________________________________________ | Phone: _______________________ |
| Father's Name: ____________________________________ | Business Phone/Beeper: __________ |
| Mother's Name: ___________________________________ | Business Phone/Beeper: __________ |
| Legal Guardian's Name: _____________________________ | Business Phone/Beeper: __________ |
Special Medical Conditions: ____________________________________________________________________
Procedures to be followed if above condition presents
an emergency:
__________________________________________________________________________________________
Any special request for the dismissal of the child
should be made on this form:
__________________________________________________________________________________________
In Case of Emergency
Persons to Contact if Parent/Legal Guardian Cannot
be Reached:
| Name: __________________________________________ | Phone/Beeper: ____________ |
In case of accident or illness, I request that the representative of the parish catechetical program contact me. If I am unable to be reached, I hereby authorize this representative to call the physician indicated and to follow the physician's instructions. If it is impossible to contact this physician, the representative of the parish catechetical program may make whatever arrangements seem necessary. I agree to assume the financial responsibility for any diagnosis, treatment and/or medication deemed necessary.
To the best of my knowledge all information given is accurate and complete. I hereby consent to, and authorize the necessary procedures that have been stated above.
Parent/Guardian Signature: ________________________________________ Date: __________________
Bus Authorization (3rd & 4th Graders 9/2003)
My child has my permission to take the bus from public school to the PSR program on Wednesday afternoons. Parent Signature: ________________________