Oak GroveMedicalPermissionFormAdult2012 by aYkc51

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									 ADULT( CHAPERONE) PERMISSION AND MEDICAL CONSENT
Name of Activity: _______________________________________________________
Participant’s Name: ______________________________________________________
                      Last        First        Middle
Birthday: _______________         Age: _________          Gender: ______

If not available in an emergency, notify:
        1. Name ______________________ Phone (_____)______________________
            Street Address _________________________________________________
            City ______________________     State ___________ Zip _____________
        2. Name _____________________ Phone (_____)_______________________
            Street Address __________________________________________________
            City ______________________     State ___________ Zip _____________

Do you have any allergic reactions to:
      Penicillin     ___________________________
      Other Drugs ___________________________
      Insect Stings ___________________________
      Ivy Poisoning, etc. ________________________
      Hay Fever      ___________________________
      Other          ___________________________
                     ___________________________

Do you have any medical conditions?              ________ YES _______ NO

If yes, describe the problems or illnesses: ______________________________________
________________________________________________________________________
________________________________________________________________________

List any medications you are currently taking: __________________________________
________________________________________________________________________
________________________________________________________________________




                               Please see other side.
                                        Insurance Information

State the name, address, medical specialty, and phone number of your primary care
physician who should be consulted in the event of emergency or medical problems
involving you:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Name if Insurance CO.
________________________________________________________________________
Address:
________________________________________________________________________
Policy Number:
________________________________________________________________________
Name of Policy Holder:
________________________________________________________________________
Phone No. of Insurance Co.:
(______)________________________________________________________________




I hereby consent and give permission to Oak Grove United Methodist Church’s sponsor or any adult
counselor acting on behalf of the ministry with respect to the Activity, as agent for me, to consent to any X-
ray examination; injections; anesthesia; medical, dental or surgical diagnosis and treatment; and hospital
care and treatment advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to
practice under the laws of the state where the services are rendered, either as an outpatient or in any
hospital. To the best of my knowledge, I have listed above all of my medical allergies, medications being
taken, medical problems and other pertinent information.




Signature _________________________________ Date ____________________

Print Full Name ____________________________ Date ____________________




NOTARY: State of Georgia                County of________________________
Sworn to and scribed to before me this _________ day of ___________, 200_____.

________________________                               _________________________
Signature                                              My Commission expires
                                                                                                       Seal

								
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