Authorization for Youth Outing and

Emergency Medical Treatment for Minor Child

I,____________________ residing at_________________________________________________

(father, mother/legal guardian)

City of____________________, Connecticut, am the___________________________________________

of____________________, a minor residing at________________________________________________

City of____________________, Connecticut, who attends church functions through The Worship Center, which holds it’s Sunday services at RHAM High School, 85 Wall Street, Hebron, & Church Offices & Timothy Hall are located at 39 Prentice Hill Road, Hebron, Connecticut.

I hereby give my consent, in the event that all reasonable attempts to contact me at (____) -______-______

(name of other Parent/Guardian)

or__________________________ at (____) -_______-__________ have been unsuccessful, for the

(preferred Dentist)

(preferred Physician)

(1) Administration of any treatment deemed necessary by Dr._______________or Dr.________________

or, in the event the preferred practitioner is not available, by another licensed physician or dentist,

(preferred hospital)

(2) The transfer of the child to____________________________ or any other hospital reasonably accessible. This authorization does not include major surgery, unless the medical opinions of two other licensed physicians or dentists are concurring in the necessity for such a surgery.

The following information is needed by any hospital or practitioner not having access to the child’s medical history:

Allergies: ________________________________________________________

Medication(s) being taken: ________________________________________________________

Date of last tetanus shot: ________________________________________________________
Physical impairments: ________________________________________________________

Any other pertinent facts which a physician should be alerted to:________________________________

Insurance Carrier________________________________________________________________________

Primary Insured_________________________________________________________________________

Policy or ID#____________________________________________ Ins. Co. phone #_________________

Disclaimer: The Worship Center, it’s employee, or volunteer will not be liable for any accident or injury that occurs on any activity or outing.

This authorization will stand until revoked by me in writing:

Dated_____________________ ______________________________________

Signature (Please state relationship)

Dated ___________________ ______________________________________

Signature (Please state relationship)