Cumyf Medical Release Form 2015

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CUMYF MEDICAL RELEASE FORM 2015
Central United Methodist Church
(please complete both sides)
27 Church St.
Asheville, NC 28801
(828) 253-3316
Name ____________________________________ Birthdate ______________________
Parent/Guardian __________________________________ (Home Phone) ___________
Cell Phone #1___________________ Parent Guardian Cell Phone #2 ______________
Address ________________________________________________________________
Street & Number
City
State
Zip Code
Email Address
_________________________________________ (Print Clearly)
Email Address ________________________________
(Print Clearly)
If Not available in an emergency, notify:
Name _________________________________________ Relationship_______________
Address ________________________________________________________________
Phone (Home) ________________________ (Cell) ______________________________
Physician _____________________________________________ Phone ____________
Address ________________________________________________________________
________________________________ _____________________________
Insurance Company
Policy Number
________________________________
Name of Policy Holder
AUTHORIZATION FOR MEDICAL TREATMENT
The undersigned parent/guardian/person authorizes a leader from the Central United Methodist
Church Group to secure medical treatment for __________________________ (Name of Person)
in case of any illness or accident for which the group leader feels professional medical attention is
required. I herby give my permission to the physician selected by the group leader to hospitalize,
secure proper treatment for, and to order injection, anesthesia or surgery for the person as named.
_________________________________________ Relationship_____________ Date ________
(Signature of parent or guardian if person is not of legal age)
I understand that the above signature authorizes Central United Methodist Church acting through
its appointed group leader(s) to secure medical treatment for me.
_________________________________________ Date ________________________
(Signature of person participating)

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