St. Marcelline's Christ Renews His Parish

CRHP WEEKEND FORMS

Medical and Contact Information for Christ Renews His Parish Weekend

Please provide us with some basic Medical Information and Emergency Contacts. This information is only used for the purpose in the event of an emergency during our CRHP Weekend. A Paper form will be provided for those with no internet access. Do Not worry if you do not have all your information today. You could still enroll, all we ask is to please have your information complete prior to the weekend so that we could best ensure your safety. If there is a section you cannot provide information on that requires input, simply type unsure at this time. Questions reqarding the health form could be submitted to our e-mail address: christrenews@gmail.com

Name First Name Last Name *Full Address ex: 820 S Springinsguth Road, Schaumburg, IL 60193 Home Phone Number Cell Phone Number *Do you have any Medical Conditions we need to know?
Heart Condition Diabetes
Allergies/ Food Allergies
Convulsions/Seizures
Food Allergies
Require Daily Medications
None
*If there are medications critical to your health, please list so we are aware of in case of emergency. *To protect you from exposure to your allergies for food or other, Please list here. Please list special needs you may need pertaining medical conditions. Ex: Wheel chair access, Oxygen safe environment, Ability to store refrigerated medications. *List your Doctors Name and Phone Number ex: Dr. John Smith (847) 123-4567 *Emergency Contact #1 Name Emergency Contact #1 Relationship *Emergency Contacts Home and Cell Number. Ex: (847)123-4567 Home (847)111-1111 Cell Emergency Contact #2 Contact #2 Relationship Emergency Contact #2 Home and Cell Phone # Please provide an email address for your Emergency contact if unable to be reached by phone *Please provide your e-mail

St. Marcelline's Christ Renews His Parish

820 S Springinsguth Road, Schaumburg, IL 60193 (847) 524-4429

CRHP WEEKEND FORMS