2022-23 Student Release Form

Contact Info, medical info & release (in the event of an emergency), safety/parent pickup info, and media release form

Student Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Parent or Legal Guardian Name*
First Last
First emergency contact while student is in faith formation, under the care of an adult leader.
Parent Phone #*
Emergency Contact*
First Last
If unable to make contact with Parent or Guardian.
Emergency Contact Phone #*
relationship to child*

Is this adult a grandparent, relative, caregiver or other
STUDENT MEDICAL INFORMATION: Child's Physician*
Physician Phone #*
Insurance Company*
Policy Holder*
Policy #*
Does your child have allergies? If YES, please list*
Does your child carry medication with them? If YES, please list*
Please let us know of any special needs or challenges, so we can better serve your child? If YES, please explain*
Parent or Legal Guardian MEDICAL Consent*
The above information is complete and true. In the event of an emergency, I give authority to Good Shepherd Parish to seek medical treatment for my child. I understand an attempt to contact me will be made prior to getting any such treatment.
Electronic Signature
First Last
SAFETY OF ALL CHILDREN: Parent Pickup*
In the interest of safety and our ongoing efforts to protect children as outlined in the diocesan Safe Environment program, we ask that a parent or designated adult bring children to our faith formation sessions and pick them up. We cannot be responsible for the safety of unattended children before entering or upon leaving our buildings, especially during the dark winter afternoons/evenings or inclement weather. Besides you, who is allowed to pick up your child when sessions are ended?
Parent Pickup NOT ALLOWED
We will not release your child to anyone not listed above. Please notify the adult leader of any changes to the list during the year. Who is NOT ALLOWED to pick up your child from faith formation sessions? (please list if applicable)
MEDIA RELEASE by Parent or Legal Guardian
I give permission to Good Shepherd Parish to use any photographs, video or artwork of my child, taken during faith formation for the promotion of religious education programs or the parish's community life., on parish social media platforms.
MEDIA RELEASE DENIED by Parent or Legal Guardian
I DO NOT give permission to Good Shepherd Parish to use any photographs, video or artwork of my child, taken during faith formation for the promotion of religious education programs or the parish's community life. on parish social media platforms.
Electronic Signature*
First Last