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Please attach copy of the student medical insurance Card to

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					Today’s Date__________________

Student’s Information
Student’s Name_______________________________ Age_________ Sex (Circle):                  M    F
Date of Birth _________________ Cell Phone ________________________ T-Shirt Size (Circle):               S    M    L   XL
Allergies ____________________________________________________________________________________________
Medicine Being Taken By My Child ______________________________________________________________________
Other Information Regarding My Child’s Health That A Doctor Should Know _____________________________________
____________________________________________________________________________________________________



Parent or Guardian Information
Parent or Guardian:
Last Name ____________________________________________ First _________________________________________
Relationship to Student: _______________________________________________________________________________
Street ________________________________________________ City _________________________________________
State: _________________________ Zip _________ Email __________________________________________________
Home Phone ______________________ Work Phone _______________________ Cell Phone ______________________
Physician's Name: _____________________________________ Phone #: ________________________________________
Health Insurance Co. _______________________________________ Group #: _____________________________________
Hospital Preferred ____________________________________________


Emergency Contact Information
Name and telephone of nearest relative, or person designated as emergency contact, if parent/guardian cannot be reached:
Name: __________________________________ Phone #: _______________________ Relation to student _______________
Name: __________________________________ Phone #: _______________________ Relation to student _______________


Media Release
I grant Faith Lutheran Church and persons acting for or through them, the rights to use, reproduce, edit, assign, and/or distribute
photographs, films, videotapes and sound recordings of my student for use in any of their print or electronic materials.

Signature of Parent or Guardian________________________________________ Date: ________________________________




            Please attach a copy of the student’s medical insurance Card to this form
Authorization for Medical Treatment
         I ___________________________________, am the parent or legal guardian of ________________________________,
hereinafter, “my child”, who was born on _________________.
         My child is attending and participating in activities held by Faith Lutheran Church, located at 1602 N.W. 12th Street in the
city of Bentonville, county of Benton, and state of Arkansas, beginning on the 1st day of January 2010 and ending on the 31st day of
December, 2010. I acknowledge that these activities may take place at the above-mentioned address or at another location.
         I hereby authorize Andrew Mastic, Youth Minister at Faith Lutheran Church and his/her officers, agents, servants, or
employees who are 18 years of age or older, who supervise the activities of this Church into whose care my child has been
entrusted, to consent to medical care or dental care, or both, for my child.
         The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical,
or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered
by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray
examination, anesthetic, dental or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice
Act for my child.
         I further authorize Andrew Mastic, Youth Minister at Faith Lutheran Church and his/her officers, agents, servants, or
employees who are 18 years of age or older, who supervise the activities of this church to receive physical custody of my child upon
completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to
Andrew Mastic, Youth Minister at Faith Lutheran Church and his/her officers, agents, servants, or employees who are 18 years of
age or older who supervise the activities of this church.


         I understand that in the case of an emergency attempts will be made to contact my designated emergency contact person.
It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required, but is
given to provide authority and power on the part of the supervisor and his/her authorized designee, to exercise his/her best judgment
on what is advisable for my child’s care, upon advice of such physician, dentist, and surgeon. I understand that I am responsible for
an expenses incurred as a result of such treatment. I freely agree to the terms of this document and acknowledge that I have been
advised to consult with an attorney before signing if I have any questions concerning the legal effect of this document.


Signature of Parent or Legal Guardian _________________________________ Dated _______________________, _________


Notary Information                                                                                     Notary Seal
State of _________________ County of ______________________________
Sworn to and subscribed to me this ________ day of ____________, ________
Signature: _______________________________________________________
My commission expires on _________________________________________

				
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