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Word of Life Senior Youth
Group - Blanket Medical Release 2005-2006 (Print)
To Whom It May Concern:
As a parent and/or guardian I so herewith authorize the treatment,
by a qualified and licensed medical doctor of the following
minor, in the event of a medical emergency, which in the opinion
of the attending physician, may endanger his or her life,
cause disfigurement, physical impairment, or undue discomfort
if delayed. This authority is granted only after a reasonable
effort has been made to reach me.
Name of Minor: _______________________________
This being a blanket permit will cover any and all outings
and events my teen will participate in within the Sr. Youth
Group during the 2005- 2006 club year. This release will be
in effect starting September 2005 and continuing until August
31, 2006. My signature also serves to indicate my willingness
to take full medical expense responsibilities for stated minor
and to release the Geary Baptist church and the leaders from
this liability.
_______________________________________
Signature (parent / legal guardian)
Street Address: __________________________ Phone: ___________________________
______________________________________
Postal Code: _______________________
Family Physician: ___________________________ Phone: _________________________
Specific medical allergies, chronic illnesses, or other conditions:
_______________________________________________________________________
Other contact in case of emergency:
Name: __________________________________ Phone: _____________________
I, ______________________agree to cooperate with group leaders
and other church leaders concerning facility rules and policies
in place for appropriate conduct and safety of myself and others.
I understand that this applies to my conduct on the premises,
as well as when we are participating in a group function away
from the church building. I also agree that when I attend club
or other group functions, that I will stay with the group for
the duration of the event: returning by the same means I went,
unless previously arranged between leaders and parents. I also
understand that I participate in all activities at my own risk.
_________________________________________________
Signature of Teen ________________________Date
This Medical Release will be carried
by leaders on each outing and / or event.
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