Medical Authorization Form

Medial Authorization is required for all Youth Group and Kidz Club activities. It is valid for one year from date signed.

Group Name:*
Please mark the appropriate group you are registering for.
If "Other" above, please enter the name of the group or activity you are registering for.
Name*
First Last
Birth Date*
MM slash DD slash YYYY
Home / Primary Phone*
Address*
Street Address City State ZIP Code
Allergies, Health Concerns, Dietary Needs*
List all allergies, health concerns (asthma, etc.), and any dietary restrictions, or "none".
Medications*
List all medications and dosages, or "none".
Date of last Tetanus shot*
MM slash DD slash YYYY
Surgery or serious illness history*
Briefly list with approximate dates, or "none".
Physician's Name*
First Last
Physician's Phone*
Insurance Company*
Name of Insurance Company or "none"
Insured's Name*
Enter name as it appears on card, or "n/a".
Group Number*
Enter Group number, or "n/a".
ID Number*
Enter ID number, or "n/a".
Parent (or guardian or adult participant 21 years of age or older):*
My child may participate with the above stated group, including travel during the event via church vehicle or automobile driven by an adult chaperone/leader that is 21 years of age or older with a valid driver's license. I give permission for my chile/myself to receive emergency medical care if necessary. I give the adult chaperones/leaders the authority to act on my behalf with respect to my child's own health and safety while at the event, with the understanding the I/emergency contact listed above will be contacted as soon a possible should the need arise. I accept full responsibility for any expenses for medical treatment for my child/myself. I release the Presbyterian Church of Portersville and its representatives from liability in the event of accidental injury or illness. Signed:
Date*
MM slash DD slash YYYY
Parent / Guardian Name*
First Last
Emergency Contact Name (if different from above)*
First Last
Emergency Phone*
Relationship*

This form is valid for one year from the date signed. Any change to your insurance requires a new form. Please notify the group leader as soon as you are aware of any changes which need to be made.

Thank you.