Student's Name
MM slash DD slash YYYY
Name of Legal Guardian
Name(s) of Person with Whom the Student Resides
Permission to Contact Non-Custodial Parent (if applicable)
An authorization of the provision of emergency treatment for students who become ill or injured while involved in a Youth Ministry function. PLEASE LIST ONLY THE NAMES OF THOSE WHO HAVE AUTHORITY TO MAKE DECISIONS IN AN EMERGENCY SITUATION INVOLVING THIS STUDENT. Please list the order in which you desire contact attempts to be made based on availability.
Primary Contact Name
2nd Contact Name
3rd Contact Name
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for: 1) the administration of treatment deemed necessary by the preferred doctor indicated, or, in the event the designated, preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the student to any reasonable accessible hospital. This authorization does not cover major surgery unless the medical options of two other licenses physicians or dentists concurring in the necessity for such surgery are obtained prior to the performance of such surgery.
MM slash DD slash YYYY