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Child/Teenager Name
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Address
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City
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State
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Zip
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Phone Number
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Date of Birth
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Social Security #
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Date of Last Immunization
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I authorize any representative from Liberty Baptist Church to have the power to grant consent to any emergency medical treatment/care, including required tests, to the above named child/teenager if I or the other parent cannot be reached.
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Father
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Home Phone
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Address
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Work Phone
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Mother
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Home Phone
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Address
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Work Phone
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Relative
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Home Phone
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Address
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Work Phone
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In the event reasonable attempts to contact the above persons have been unsuccessful, I hereby give my consent for the following local medical care providers and local hospital to be called or child/teenager taken there when within reasonable traveling distance. When not within reasonable traveling distance, or in the case of long distance trips or out of state trips, I give my permission for my child/teenager to be treated at the nearest medical facility available.
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Doctor
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Phone
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Dentist
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Phone
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Medical Specialist
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Phone
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Hospital
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Phone
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This authorization does not cover major surgery unless the medical opinion of a second licensed physician or dentist concurring in the necessity for such surgery is obtained BEFORE THE SURGERY IS PERFORMED.
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Facts concerning my child's/teenager's medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted:
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Signature of Parent
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Date
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My Insurance Carrier is Policy #
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