Medical Authorization Release Form (Page 3 of 3) in pdf

Release of Liability and Authorization for Medical Treatment

In the event that (Name of your son/daughter) ________________________ becomes ill and/or sustains an

injury while attending any function or trip sponsored by the First Baptist Church of Hazlehurst, Georgia I, the

undersigned parent/guardian, give my permission to those in charge to take whatever steps deemed necessary to

stop any bleeding, to administer first aid and to secure any medical/emergency treatment.

I also give my consent to any x-rays, examination, anesthetic, medical, dental, or surgical diagnosis and

treatment, hospital care and the administration of medication to be rendered in an emergency situation, under

the general aid or specialized supervision of a duly licensed physician and or surgeon.

I, furthermore, understand and agree that a copy of this form will be as valid as an original.

I understand and agree that this signed copy releases the sponsors, chaperones, the First Baptist Church,

Hazlehurst, Georgia, its ministers, staff and employees of any and all liability (including acts of negligence) in

the event that the above named person should be injured.

I give my permission to the above mentioned chaperones and/or sponsors to secure first aid and/or medical

treatment and I, furthermore, authorize the physician to proceed with any emergency medical treatments as

deemed necessary.

I, furthermore, agree to be personally responsible for any financial obligations incurred by the above mentioned

treatments not covered by my major medical insurance.

I understand and agree that this form will be considered valid for a period of one year from the date of

signature.

Signature of Consent: ________________________________________ Date: _________________________

(This form must be signed by a parent or legal guardian in the presence of a notary.)

******************************************************************************************

(To be completed by a Notary)

The foregoing instrument was acknowledged before me this _______ day of _________________, 20____

by ________________________________, who

____ is personally known by me, or

____ produced ________________________________ as identification and did take an oath.

(Affix seal below)

_____________________________________

Notary Public

Medical Authorization Release Form Page 3