EMERGENCY INFORMATION
JULY 2002-DECEMBER 2002
Your child
cannot attend this event/trip without this information!
Parental Consent/Medical
Treatment Form
New Life Baptist Church
24634 Hwy 442
Independence, LA
70443
(225)209-0032
I, the
undersigned parent or guardian of ___________________________, a minor, do
hereby authorize adult workers with the youth of New Life Baptist Church to
consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or
treatment and hospital care which is rendered under supervision of any
physician or surgeon licensed under the provisions of the Medical Practice Act
on the medical staff of a licensed hospital, whether such diagnosis or
treatment is rendered at the office of said physician or at said hospital.
Further, as
parent or guardian of the minor named above, I do herby expressly consent that
my son/daughter may receive emergency medical treatment from any physician,
hospital, or other medical center without the necessity of first notifying me,
and do further agree to hold blameless any physician, hospital or other medical
center for rendering such services.
We also release
New Life Baptist Church and its affiliates from responsibility and liability
for any injury or illness that my child may sustain.
Insurance
Company or Group:________________________________________________________
Policy
Number:_________________________________________________
Name Of
Child:____________________________________________
Parent or
Guardian:_____________________________________________
Address:_______________________________________________________
City:_____________________________
State:_________
Zip:__________________
Daytime
Phone:__________________ Evening
Phone:________________________
Signature of
Parent or Guardian:_______________________________________________________
Allergies:________________________________________________________
Medications
Being Taken:__________________________________________________________
Other number
that we can call if we cannot contact you: ___________________________