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In case of accident or serious illness I request the school to contact me. If I cannot be reached, I hereby authorize the school to make whatever arrangements the circumstances allow. It is understood and agreed that neither the school, the teachers, nor the Catholic Diocese of Evansville is the insurer of my student’s health and safety while they are at school or engaged in school-supervised activities, including sports. I understand it to be my obligation to provide such insurance as I may desire to purchase to protect my student’s and myself against the costs of sickness or injury. If the below-named student(s) need emergency medical treatment, and neither a parent nor the designated family physician can be contacted, consent is hereby granted for such emergency treatment as may be considered necessary in the opinion of the attending physician.

Please Note: Throughout the document, the term "minor" refers to ALL Reitz Memorial students. The following form must be signed by a parent/guardian, regardless of if the child is over 18 years of age.

Please select the number of Reitz Memorial students for which you are completing the medical information card:
Minor(s)
1 Minor2 Minors3 Minors4 Minors5 MinorsMore Minors6 Minors7 Minors8 Minors9 Minors10 Minors
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First Parent/Guardian's Name

First Name*

Middle Name

Last Name*
First Parent/Guardian's Date of Birth*
I certify that I am 21 years of age or older
First Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
First Parent/Guardian's Signature*
Second Parent/Guardian's Name

First Name*

Middle Name

Last Name*
Second Parent/Guardian's Date of Birth*
Second Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Third Parent/Guardian's Name

First Name*

Middle Name

Last Name*
Third Parent/Guardian's Date of Birth*
Third Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Fourth Parent/Guardian's Name

First Name*

Middle Name

Last Name*
Fourth Parent/Guardian's Date of Birth*
Fourth Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Fifth Parent/Guardian's Name

First Name*

Middle Name

Last Name*
Fifth Parent/Guardian's Date of Birth*
Fifth Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Sixth Parent/Guardian's Name

First Name*

Middle Name

Last Name*
Sixth Parent/Guardian's Date of Birth*
Sixth Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Seventh Parent/Guardian's Name

First Name*

Middle Name

Last Name*
Seventh Parent/Guardian's Date of Birth*
Seventh Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Eighth Parent/Guardian's Name

First Name*

Middle Name

Last Name*
Eighth Parent/Guardian's Date of Birth*
Eighth Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Ninth Parent/Guardian's Name

First Name*

Middle Name

Last Name*
Ninth Parent/Guardian's Date of Birth*
Ninth Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Tenth Parent/Guardian's Name

First Name*

Middle Name

Last Name*
Tenth Parent/Guardian's Date of Birth*
Tenth Parent/Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive newsletters, announcements and news throughout the school year
Family Information

Home Phone

Mother's Name

Mother's Email

Mother's Cell Phone

Father's Name

Father's Email

Father's Cell Phone
Do the Parents live together?*
Yes
No

With whom is the student's primary residence with? *

Is there anyone by court order or decree that is designated as the primary or sole custodial parent?

Is there anyone who has been restrained from picking up the student(s)?

Is there anyone who is authorized to pick up the student(s) other than a parent?

Hospital Preference *
Emergency Contacts - If Parents Cannot be Reached

Emergency Contact 1 *

Emergency Contact 1 Phone Number *

Emergency Contact 2 *

Emergency Contact 2 Phone Number *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 21 years of age or older
Parent or Guardian's Information

RMHS Student's Nickname

Physician Name *

Physician Phone Number *

List any chronic or existing diseases or medical problems (e.g. diabetes, epilepsy, food allergies, insect allergies, latex allergies, etc.)

List any instructions for care of the above if it becomes necessary at school

List any medications and dosage your student is taking on a regular basis
RMHS Year of Graduation*
T-Shirt Size*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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