Good Samaritan Formation Registration

Good Samaritan 2021-22 Children/Youth Formation Registration

Note: if you are not registered with either church please fill out the parish member form found on the Good Samaritan Page, the newcomer form found on the St. Gabriel home page or you can pick one up at the church.

Emergency Medical Treatment Release

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers contact:

Other Medical Treatment: In the event it comes to the attention of the parish, its officers, directors and agents, the Diocese of Richmond, chaperones or representatives associated with the activity, that my child becomes ill with symptoms such as a headache, vomiting, sore throat, fever, diarrhea, I will be called and will pick up my child when notified.

Medications: My child is taking medication at present. My child will bring all such medications necessary and such medications will be in the original container. Names of medications and concise directions for seeing that the child takes such medications, including dosage and frequency of dosage are as follows:

Specific Medical Information: The parish will take reasonable care to see that the following information is held in confidence.


OR CLICK HERE to download a copy of the form for you to print and bring completed form to the parish, mail to Good Samaritan Catholic Church, 8901 Winterpock Road, Chesterfield, VA 23832.

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