Medical Treatment Authorization & Release For Minors
Christ Fellowship Church
15600 New Hampshire Avenue Silver Spring, MD 20906 301-384-0281
To Whom It May Concern:
As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed Medical Doctor in an emergency which, in the opinion of Christ Fellowship Church and/or it’s agents, may endanger my child ______________________________’s life, cause disfigurement, physical impairment, or undue discomfort if delayed. This includes surgery, anesthesia, and/or other procedures that the physician may deem necessary. The authority is granted only after a reasonable effort has been made to reach me. Name of Minor: _______________________________ Relationship: _____________________ This release and authorization for _________________________ is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence. I also accept responsibility for any medical expenses as a result of any injury sustained. Signed: ________________________________________________ Date: _________________ Contact Phone #s: Home __________________ Cell _______________ Work ______________ Alternative Contact Person: _______________________________________________________ Relationship: _____________________________ Phone: _____________________________
Family Physician: _____________________________ Phone: _____________________ List any known allergies, illnesses, injuries or other pertinent comments:
Is this Child on Medication?
_____ Yes
_____ No
If Yes, please fill out a Medication Directive (Form 203-A) for each fieldtrip.
Health Insurance Data: Company: ________________________________ Policy #: ______________________________
Group #: __________________________ Policy Holder’s Name: ___________________________ Copy of this form is valid as the original. Form - 202-A