Medical English

Medical Form - Faith Formation

If you wish to print and mail the registration form, it can be found at the following link:

Faith Formation Office: (219) 362-2509 or stpeter@catholiclaporte.org.
St. Peter Religious Education Center
1104 Monroe St.
LaPorte, IN 46350

Medical Form - Faith Formation

* Indicates required field

Name of Student *

First

Last

Date of Birth (MM/DD/YY) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Mother's Name *

First

Last

Father's Name *

First

Last

Mother's Best Phone Number *

Father's Best Phone Number *

In case of divorce or separation, the child resides with? *

Family Doctor's Name: *

Insurance Name: *

Family Doctor's Phone Number: *

Policy Number *

Hospital Preference: *

Hospital Preference "Other" *

Allergies or Medical Needs *

Date of Last Tetanus Vaccination *

Immunization up to date? *

Please list the names and phone numbers of three responsible persons we can contact if you are unreachable in an emergency:

Name 1 *

Name 2 *

Name 3 *

Phone Number 1 *

Phone Number 2 *

Phone Number 3 *

Relation 1 *

Relation 2 *

Relation 3 *

Authorization for Treatment of a Minor

I, the parent or legal guardian of the student listed, give my consent for emergency medical and surgical treatment of this minor in a licensed hospital by a licensed Indiana physician should his/her conditions so require in my absence. I understand that in such case reasonable attempts would be made to first contact me, time and conditions permitting.

As long as the medical or surgical treatment considered necessary in the situation is in accordance with generally accepted standards of medical practice for the particular type of injury or illness involved, I impose no specific limitation or prohibitions regarding treatment unless indicated below. I assume financial responsibility for the same.

Limitations/Prohibitions: *

Parent or Legal Guardian Signature (type name) *

First

Last

Date (MM/DD/YY) *

Submit

Medical Form - Faith Formation

Medical Form - Faith Formation

Contact Us

To Mail in your financial support, please make a check out Holy Family Parish and mail it to:

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