St. Clare of Montefalco Parish

A Catholic Community in
Detroit and Grosse Pointe Park, MI USA

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Medical Release Form

- Religious Education Medical Release Form
  
  The maximum number of form submissions has been reached. This form is currently not available.
  
  As parent/guardian, I do hereby authorize the treatment by a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.
  
  Reason for which release is intended REQUIRED To attend St. Clare Religious Education Program To attend St. Clare Vacation Bible School Please fill out this field.
  
  Parent Information
  
  Parent Name Please enter valid data.
  
  Parent Phone Number (where you can always be reached) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Physician Information
  
  Family Physician REQUIRED Please fill out this field. Please enter valid data.
  
  Physician Address REQUIRED Please fill out this field. Please enter valid data.
  
  Physician Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Health Insurance Information
  
  Company Please enter valid data.
  
  Policy Please enter valid data.
  
  Group Please enter valid data.
  
  Contract Please enter valid data.
  
  Minor Child REQUIRED Please fill out this field.
  
  Child Name 1
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 2
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 3
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 4
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 5
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 6
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 7
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 8
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 9
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 10
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 11
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 12
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 13
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 14
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 15
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 16
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 17
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 18
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 19
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  Child Name 20
  
  Name of Child REQUIRED Please fill out this field. Please enter valid data.
  
  Child's Relationship to you: Please enter valid data.
  
  List of allergies, medication, or other pertinent comments:
  
  I further authorize the person who presents the minor to sign the Acknowledgment of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician. I acknowledge that it is my responsibility to submit a new form if any of the above information changes.
  I Agree Please select this field.
  
  Submitting this form will act as your signature on the Medical Release Form
  I Agree Please select this field.
  
  Submit
  
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- Contact Us
  
  Parish Office
  
  313-647-5000
  secretarystclarem.org
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