Facebook Twitter Instagram YouTube

Parental Authorization Form

- Parent Resources

Parental Authorization Form 2019-2020
The maximum number of form submissions has been reached. This form is currently not available.
- Student Information
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field.
- Parent/Guardian Name: REQUIRED Please fill out this field. Please enter valid data.
  
  OF
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- A. AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT:
  
  In the event I cannot be contacted to give my consent, I hereby authorize Holy Family Academy, its officers, agents, and employees in my place for:
  
  1. The administration of any treatment deemed advisable by a licensed physician or dentist.
  2. The transfer of the minor to any hospital or clinic reasonable accessible.
  
  IF PRACTICABLE UNDER THE CIRCUMSTANCES, I AUTHORIZE HOLY FAMILY ACADEMY TO CONTACT MY CHILD'S PHYSICIAN.
- Physician Name: REQUIRED Please fill out this field. Please enter valid data.
- Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- I understand this authorization is given to provide authority and power on the part of Holy Family Academy, its officers, agents, and employees to give specific consent to any examination, diagnosis, treatment, or hospital care which, in the judgment of a licensed physician or dentist, is deemed advisable.
- B. AUTHORIZATION TO PARTICIPATE IN ATHLETICS AND OTHER ACTIVITIES:
  
  I hereby give my consent for the above-named student to participate in the athletic programs and other programs of Holy Family Academy.
- C. AUTHORIZATION TO PARTICIPATE ON FIELD TRIPS
  
  I hereby give my consent for the above-named student to attend and participate in field trips associated with Holy Family Academy. I give permission for the above-named student to travel by van/car with a parent or HFA faculty member.
- I understand that Holy Family Academy does not assume any responsibility in case any accident or injury occurs. In consideration for the above-named student being permitted to make such trips, take part in such activities, and receive the agreed-to medical treatment and /or medication , I hereby agree to waive all claims release, indemnify, defend and hold harmless Holy Family Academy, its Trustees, Directors, Heads of School, Faculty , agents, employees and invitees, together with all persons, including parents of students of Holy Family Academy assisting with any phase of such trips and activities (excluding paid certified carriers not affiliated with Holy Family Academy), from any and all claims, suits, losses, damages, causes of action or other liabilities, including all expenses of litigation and/or settlement which may arise in connection with such trips and activities. I hereby also agree to waive all claims, release, indemnify, defend and hold harmless all of said parties from any and all liability by reason of any accident or injury suffered by the above-named student while on such trips or participating in such activities. I hereby further expressly agree that such indemnity will apply whether the claims suits, losses, damages, causes of action or other liabilities arise in whole or in part from any form of negligence of said parties.
- I understand that Holy Family Academy does not assume any responsibility in case any accident or injury occurs. In consideration for the above-named student being permitted to make such trips, take part in such activities, and receive the agreed-to medical treatment and /or medication , I hereby agree to waive all claims release, indemnify, defend and hold harmless Holy Family Academy, its Trustees, Directors, Heads of School, Faculty , agents, employees and invitees, together with all persons, including parents of students of Holy Family Academy assisting with any phase of such trips and activities (excluding paid certified carriers not affiliated with Holy Family Academy), from any and all claims, suits, losses, damages, causes of action or other liabilities, including all expenses of litigation and/or settlement which may arise in connection with such trips and activities. I hereby also agree to waive all claims, release, indemnify, defend and hold harmless all of said parties from any and all liability by reason of any accident or injury suffered by the above-named student while on such trips or participating in such activities. I hereby further expressly agree that such indemnity will apply whether the claims suits, losses, damages, causes of action or other liabilities arise in whole or in part from any form of negligence of said parties.
  I AGREE to the above statements Please select this field.
- By typing your name in the space below, you are acknowledging that the above information is correct.
- Parent/Guardian Signature REQUIRED Please fill out this field. Please enter valid data.
- Relation to student REQUIRED Please fill out this field. Please enter valid data.
- Date REQUIRED Please fill out this field. Please enter a date.
- Email REQUIRED Please fill out this field. Please enter an email address.
Submit

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Parental Authorization Form

Parental Authorization Form 2019-2020