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HEALTH FORM

- Ministries

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- Diocese of Stockton
  
  Emergency Health / Medical Information and Consent
  
  In the event of an emergency, I, the undersigned parent/guardian of the child named on this form, hereby gives permission to the Roman Catholic Bishop of Stockton, the Pastor, employees, agents, representatives, Chaperons and adult volunteers (the Designated Person(s)) to arrange for and authorize emergency medical, dental, or surgical treatment for my child, as considered necessary by the attending physician or dentist. I wish to be advised prior to any further post-emergency treatment by the hospital, doctor or dentist.
- Family Doctor REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Family Dentist REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Insurance Carrier REQUIRED Please fill out this field. Please enter valid data.
- Policy Number REQUIRED Please fill out this field. Please enter valid data.
- In case of emergency PLEASE CONTACT REQUIRED Please fill out this field. Please enter valid data.
- Relationship Please enter valid data.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- By checking this box I wish to be notified IMMEDIATELY of NON-EMERGENCY medical conditions (e.g. headache, vomit, sore throat, fever, diarrea)
  I Agree Please select this field.
- By checking this box I acknowledge that my child is taking medication that will need to be administered by my child or DESIGNATED PERSON
  
  Please list any medications below
  I Agree Please select this field.
- Medications
- Medication Administration NONE Non-Prescription ONLY Prescription ONLY Any Medication
- Please provide any specific information/instructions as necessary
- Allergies (meds, foods, plants, insects, etc)
- Dietary Restrictions
- Physical Limits
- Other
- By checking this box you accept the agreement that you are submitting this form digitally and that your typed name acts as your signature.
  Acknowledge Digital Signature Please select this field.
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
Submit

All Saints University Parish

Turlock, CA

Diocese of Stockton

HEALTH FORM