Medical Authorization Form and Parent Permission


From the Open Files of:

NW Synod of Wisconsin Resource Center (715) 833-1153

Contributed by:

This file is available in
Rich Text Format version for editing

Medical Authorization Form and Parent Permission
Northwest Synod of Wisconsin - ELCA
Lutheran Youth Organization

Medical Authorization must be signed by parent or guardian (or by attendee if over 18).

Registrant Name

______________________________________________

Parent/Guardian (first and last name)

______________________________________________

Address

______________________________________________

City State Zip

______________________________________________

Emergency phone - night

______________________________________________

Emergency phone - day

______________________________________________

Insurance Company

______________________________________________

Policy Number

______________________________________________

Important Medical Information

______________________________________________

 

My son/daughter has permission to engage in all Synod Youth Activities. In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by Synod staff to secure proper treatment for My child as named above.

______________________________________________

___________________

parent/guardian signature

date

______________________________________________

___________________

participants signature

date


[ RESOURCES ] • [ HOME ]

© Copyright 2001 by the Northwest Synod of Wisconsin Resource Center. Please see our usage policy.

NW Synod of Wisconsin Resource Center