Knights of Columbus
PSR Medical Information Form
2019-2020 PSR Medical Information Form
Fill out ONE form per family.
During PSR class I can be reached at
If you are unable to be reached in case of an emergency, whom should we call?
I authorize emergency treatment to be administered to the above named child/children.
I understand that every attempt will be made to reach me, but if the severity of the injury indicated the necessity, the emergency response system may be called.
TERMS OF ACCEPTANCE and SIGNATURE
I acknowledge that the information provided in this form is correct.
Please type your first and last name
I understand that checking this box constitutes a legal signature.