St. Boniface Youth Group
MEDICAL CONSENT/ LIABILITY RELEASE

    As parent/guardian of ________________________________, I give permission for my child to attend and participate in all activities and events sponsored by or participated in, by the Saint Boniface Church, 5615 Midnight Pass Road, Sarasota , FL, their Youth Leaders, and advisors.
I also give permission for my child to ride in a church sponsored vehicle designated by the adult leader in whose care my child has been entrusted while attending and participating in activities sponsored by Saint Boniface Church.
    I authorize an adult, in whose care my child has been entrusted, to secure proper medical treatment in the event of an emergency. I authorize any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under general or special supervision and on the advise of any physician or dentist licensed under the provisions of the Medical Practices Act on the medical staff of a licensed hospital whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
    The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this otherwise, the undersigned shall assume all transportation costs.
    I release Saint Boniface Church, its staff, employees, and volunteers from all liability due to any injury to my child while he/she is participating in any event or activity sponsored by Saint Boniface Church.

Please list any allergies, prescriptions, or medical information about your child. 

Student Date of Birth: _________________________________

Allergies: _____________________________________________________________________

Medications: ___________________________________________________________________

Medical Concerns: ______________________________________________________________

Insurance Company:_____________________________________________________________

Policy Number: ____________________________________

Physician: _______________________________________ Telephone: ____________________
 
Parent/Guardian Name(s): ________________________________________________________

Parent/Guardian Signature(s): ___________________________________    Date: ____________

Parent/Guardian Phone: __________________________________________________________

Parent Notes/Comments: _________________________________________________________