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Any other Information (special needs, concerns):
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Doctor: ______________________________Phone:________________________
Insurance ID# ______________________________Name on insurance card: _______________________
I give permission to the leaders of FUMC Youth to authorize emergency medical procedures for
my child. They may also transport my child to and from _______________________(hospital).
Parent/Guardian signature: _______________________________
EMERGENCY MEDICAL AUTHORIZAION
I give my consent for emergency medical treatment by a certified first aider. In the event that additional
treatment is needed, the staff of the Emergency room of the hospital listed above, or one closest to the event
location, has my permission.
Parent/Guardian Signature________________________________Date:___________________________
Address__________________________________________________________________________
Phone (home) _________________________Work (work) ____________________________
Hospitalization plan and Group No.:___________________________________________________________