Teen Permission Slip/Medical Authorization

My child (children)______________________, has (have) permission to participate in the Teen Christian Education program of Agape Christian Church for all its scheduled activities. I understand that in the event of an emergency or injury, every effort will be made to contact me. In the event I cannot reasonably or timely be contacted, I, as the parent and/ or guardian of the above named child, do authorize Agape Christian Church youth leaders to make all decisions and take all actions regarding the medical care and treatment of my child, including the employment of the services of any physician, nurse, hospital, or medical provider. I further release, discharge, and agree to hold harmless and indemnify all appointees from any and all liabilities arising out of their exercising, or failing to exercise, the authorization.

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Parent/ Guardian
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Address
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Home Phone Work Phone
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Cell Phone or Pager Number
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Contact if you are not available Relationship
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Address
_______________________________ ____________________________________
Home Phone Work Phone
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Teen Permission Slip/Medical Authorization

Medical Insurance
Insurance Company___________________________________________________
Policy Number_______________________________________________________
Policy Holder_______________________________________________________
Child
Name________________________________________________________________
Date of Birth_______________________________________________________
Medication/Drug Allergies___________________________________________
Medical Problems/Conditions_________________________________________
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Family Doctor_____________________________Phone#____________________
Special Information or Limitations on Authorization_________________
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Date:______________________Signature:_______________________________
Parent/Guardian