ST. BERNARD'S MEDICAL INFORMATION AND RELEASE FORM
Please Print
Student: ______________________________ Date Of Birth ___/___/___ Age____ Sex _____
                       (Last Name)              (First Name)          (Initial)
Address _____________________________ City ____________ Zip _______ Grade ______
Parent / Guardian: ________________________________________ Phone: ______________
Other Emergency Contact: _________________________________  Phone: ______________
Other Information   Social Security #: __________ Date of Last Tetanus Booster: ___________
****** List any allergies: _____________________________________________________
List any medications being taken at this time: _________________________________________
List any medical conditions / pertinent health information we should be aware of: ______________
___________________________________________________________________________

MEDICAL RELEASE
I / We, the undersigned parent(s) or legal guardian(s) of (child's name) _____________________ do hereby authorize any x-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any licensed physician or dentist and / or hospital service that may be rendered to said minor under the general, specific or special request of Reverend Bernard Jewitt, Reverend Patrick Eastman, Chad Taber, or Sharon Lechtenberg.  This consent will remain effective from August 15, 2001 until August 15, 2002.  I understand that every precaution will be take to ensure my daughter / son / ward's safety.  Should an accident occur, I will not hold St. Bernard's Parish or the Diocese of Tulsa or its paid staff or volunteer staff responsible.  Further, I understand that attempts will be made to immediately contact me should an accident occur.  If the parish is unable to contact me, I understand that an ambulance or emergency personnel will be notified.  Payment for medical emergencies is the responsibility of the parent / guardian.
Signature of Parent / Guardian: ________________________________ Date: ______________
 
In case of an emergency and parents / guardians cannot be reached, an ambulance or emergency personnel will be notified.  Payment for medical emergencies is the responsibility of the parents / guardians.
Signature of Parent / Guardian: ________________________________ Date: ______________

INSURANCE / PHYSICIAN INFORMATION
Physician's Name:  _________________________________________ Phone: _____________
Address: _____________________________ City: ______________ State: ____ Zip: _______
Insurance Carrier: ____________________________ Policy Number: ____________________
Please fill out the Prescription Medication Form if your child
will need to take medication during the Religious Education Classes,

and attach it to this form.