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Medical Release & Liability Form

- Faith Formation

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- Family Name REQUIRED Please fill out this field. Please enter valid data.
- Name of person completing this form
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Medical Release Acknowledgement
- I authorize emergency medical treatment to be given to my child(ren).
  I Agree Please select this field.
- Emergency Contact Information
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Relationship to Child(ren) REQUIRED Please fill out this field. Please enter valid data.
- Medical Insurance
- Insured Name
- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Name of Medical Insurer Please enter valid data.
- Policy Number Please enter valid data.
- Group ID# Please enter valid data.
- Doctor Name Please enter valid data.
- Doctor Phone Number Please enter a phone number.
- Preferred Hospital Please enter valid data.
- Release of Liability
  
  In consideration of St. Paul the Apostle Catholic Church accepting my child’s registration in the Religious Education Program, I/we release, hold harmless and discharge St. Paul the Apostle Catholic Church and the Diocese of Harrisburg, their officers, trustees, employees, agents, and catechists of and from any and all liability, claim, damage, cost or expense, except in the case of willful/intentional harm or gross negligence and waive any such claims against any such person or organization in connection with the Church of the Diocese of Harrisburg.
  I Agree Please select this field.
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