Text Box: MEDICAL PERMISSION FORM Joliet Diocese Medical Permission I grant permission for the administration of First Aid to my child _________________________________, By the people in charge of St. Joseph Youth Ministry, and those transporting my child to and from the program as their judgement deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent / guardian of the participant. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery, if deemed necessary for my child. Print Youth’s Name _________________________________________ Birth date __________________ Allergic to medication / other? No __________ Yes___________ What? _________________________ ______________________________________________________________________________________ Medication(s) presently taking: ____________________________________________________________ ______________________________________________________________________________________ Insurance Information Policy in the name of: __________________________________________________________________ Insurance Company: __________________________________________________________________ Policy Number: __________________________________________________________________ Identification Number: __________________________________________________________________ Social Security Number: __________________________________________________________________ Authorized Physician: ___________________________________ Phone: _______________________ Signature of Parent / Guardian: ______________________________________ Date:_________________ Address: ______________________________________________________________________________ Day Phone: ______________________________ Evening Phone: _______________________________