Diocese of Ogdensburg

The Roman Catholic Church in Northern New York

Medical & Parental Permission Form
Participant Information
Last Name:(*)
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First Name:(*)
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Middle Name:(*)
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Date of Birth:(*)
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Year in School:(*)
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Gender:(*)
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Email Address:(*)
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Street Address:(*)
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City:(*)
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State:(*)
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Zip Code:(*)
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Fill out address below only if different than participant. Please include phone numbers.
1) Parent or Guardian:(*)
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Street Address:
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City:
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State:
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Zip Code:
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Home phone:(*)
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Work phone:
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Cell phone:
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Fill out address below only if different than the participant. Please include phone numbers.
2) Parent or Guardian:
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Street Address:
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City:
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State:
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Zip Code:
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Home phone:
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Work phone:
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Cell phone:
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Emergency Contact
Emergency Contact:(*)
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Relationship to participant:(*)
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Home phone:(*)
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Work phone:
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Cell phone:
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Medical Information
Physician:(*)
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Office Phone:(*)
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Medical Insurance Company:(*)
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Medical Insurance Policy#:(*)
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If necessary, describe the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability or condition to which your child is subject and/or which the staff should be aware, and what, if any, action or protection is required on account thereof. Please submit this notification in writing and attach it to this form.
Allergies, Check all that apply:
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Bee Sting: (Action Required)
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Drugs: (Action Required)
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Other: (Action Required)
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Date of last Tetanus Shot:(*)

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Does your child wear:
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Please list all medications and dosages (prescription and non-prescription) being sent with your child. All medication will be collected at registration and dispensed by the event’s health coordinator.
Medication:
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Dosage:
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Medication:
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Dosage:
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Medication:
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Dosage:
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Medication:
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Dosage:
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Medication:
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Dosage:
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(*)
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(*)
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Full Name of Parent or Guardian:(*)
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By typing your full name in the Full Name of Parent or Guardian field above you certify that everything in this form is true and that you understand what is being asked of you.

Today's Date:(*)

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I am not a Robot:
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Any Additional Comments:
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Please make sure you fill out the Activity Release, Code of Conduct and General Rules, Medical & Parental Permission and Photo Release Form after you have registered and paid.