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
_____________________________________________________________________________________
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:
______________________________________________________________________________________
______________________________________________________________________________________
Indicate the name and number of your medical insurance: _______________________________________
______________________________________________________________________________________
Full name of parent for whom the policy is written: ____________________________________________
The trip will depart: date_________________ place________________________time_____________
The group will return: date_________________place________________________time______________
Please include a copy of your medical insurance card.
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