Primary Adult Contact - For All Contact Information
Family and Medical Information
The following information will be used for a Medical Treatment Release Form
To Whom It May Concern:
As parent/guardian, I do hereby authorize the treatment of a qualified and licensed physician of any condition which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after reasonable effort has been made to reach me.
This form is intended for use only during Religious Education time.
I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility.
This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician. I acknowledge that it is my responsibility to submit a new form in any of the above information changes.
*By entering my name in the box above, I am providing my digital signature on the Form.
Please contact the RE office if we should be aware of a particular family or parenting situation.
There are several payment options available, including a pay later option. Please click the arrow to select your choice of payment. Approval is needed for or scholarship option, please call 248-693-9555.