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

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