Child Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Primary Contact *

(###)

###

####

Secondary Contact

(###)

###

####

Attends CCD? *

No

Yes, at St. Raphael-Holy Angels

Yes, at another parish (If so please specify below)

Date *

Today's Date

MM

DD

YYYY

Parent Authorization *

By selecting yes below, I certify that to the best of my knowledge, the child named above is in excellent physical health and is capable of taking part in the CYO athletic activity or activities for which he/she is registering. I hereby give my approval for his/her participation in CYO basketball and/or cheerleading. I understand that all athletic activities involve the risk of injury and in case of injury to my child, I agree to waive all claims resulting from or in connection with the activities in which my child is a participant. I hereby release, absolve and hold harmless the coaches, directors and St. Raphael-Holy Angels Parish from any such claims. Also, in the event of an emergency, I hereby give permission to my child’s coach(es) to arrange for transportation for my child to receive any necessary medical attention in the event that I am not present and am unable to be reached.

Yes

Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Authorization *

By checking yes below, As a parent and/or guardian of (Fill out next field below), I authorize treatment by a qualified and licensed medical doctor in the event of a medical emergency, which, in the opinion of the attending physician, may endanger my child's life, cause disfigurement, physical impairment on undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Yes

Parent/Guardian of, *

Please put child's name here.

First Name

Last Name

Name of Parent/Guardian *

First Name

Last Name

Daytime Phone *

(###)

###

####

Cell Phone *

(###)

###

####

Evening Phone *

(###)

###

####

Pediatrician *

First Name

Last Name

Pediatrician Phone *

(###)

###

####

Other person to contact in case of emergency *

First Name

Last Name

Daytime Phone *

(###)

###

####

Cell Phone *

(###)

###

####

Evening Phone *

(###)

###

####

Approval *

By checking yes below, This release form is completed and signed of my own free will for the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Yes

Date *

Today's Date

MM

DD

YYYY