STATE OF NORTH CAROLINA

COUNTY OF BLADEN

MEDICAL AUTHORIZATION FOR TREATMENT OF A MINOR

For good and valuable consideration, I do hereby release and forever discharge the Presbytery of Coastal Carolina, its officers, members, agents, assigns, and chaperones from any and every right, claim or demand which I have or might otherwise hereafter have against them on account of, connected with or growing out of its sponsored trip

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on the date(s) of: ________________________________________________________________________

I request and authorize hospital medical personnel, agents and employees to provide all reasonably necessary medical care including, but not limited to hospital tests, such as pathology, radiology and anesthesia, surgery and prescription drugs advisable for the health of my child.

I acknowledge that no representatives, warranties, or guaranties as to the results or cures will be made.

The name of the child covered by this authorization is:

NAME OF CHILD: _____________________________________________________________________

DATE: _______________________________________________________________________________

SIGNED: (Parent/Legal Guardian): _________________________________________________________

ADDRESS: ____________________________________________________________________________

TELEPHONE __________________________________________________________________________

WITNESS: ____________________________________________________________________________

Please note any special instructions such as medical problems or allergies if an emergency should develop:

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Indicate the name and number of your medical insurance: _______________________________________

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Full name of parent for whom the policy is written: ____________________________________________

The trip will depart: date_________________ place________________________time_____________

The group will return: date_________________place________________________time______________