Church Permission Slip And Church Health Form printable pdf download

CHURCH PERMISSION SLIP AND CHURCH HEALTH FORM

TO WHOM IT MAY CONCERN:

____________________________________________ has my permission to go with the CHURCH OF THE

LIVING CHRIST OF LOYSVILLE, PA YOUTH GROUP to __________________________________, _______

(Event and Location)

(State)

on __________________________, ____________.

(Date)

(Year)

__________________________________________________________

(PARENT / GUARDIAN SIGNATURE)

CONSENT TO TREATMENT OF A MINOR

The undersigned parent or guardian of_____________________________________________a minor,

does hereby authorize adult leaders of the youth of the Church of the Living Christ of Loysville, PA as

agents for the undersigned, to consent to any examinations, x-ray, anesthetic, medical or surgical

diagnosis and hospital care which is deemed advisable by a qualified physician or local hospital. I will

assume responsibility for fees incurred by such an emergency.

Insurance Company and Policy Number___________________________________________________

Signature of Parent or Guardian_________________________________________________________

Address _________________________________ City ______________________ Zip_____________

Telephone (Home) ________________________________ (Work)_____________________________

Additional Emergency Contact _________________________ Telephone _______________________

Minor’s Birthdate ________________________________ SS#________________________________

PLEASE LIST ANY ALLERGIES, MEDICATIONS, ETC. AND DATE OF MOST RECENT

TETANUS SHOT OR BOOSTER.

ALLERGIES _________________________________________________________________________

MEDICATIONS ______________________________________________________________________

MOST RECENT TETANUS SHOT/BOOSTER ______________________

OTHER SPECIAL CONDITIONS: ________________________________________________________

___________________________________________________________________________________

EXPLANATION _______________________________________________________________________

FAMILY DR.’S NAME ________________________________

PHONE NUMBER__________________

Church Permission Slip And Church Health Form