AWANA 2008/2009

Salem Baptist Church
24032 Sparta Road
Sparta, VA  22552
(804) 633-5583

MEDICAL EMERGENCY CARE INFORMATION FORM

As parent or guardian of the named child I hereby give my consent to administer necessary medical treatment by a qualified and licensed medical doctor in the event of a medical emergency, which in the opinion of the attending physician, may endanger the life of my child, cause disfigurement, physical impairment or undue discomfort if delayed.  I give my consent to transport by ambulance if the situation warrants such action.  My signature also serves to indicate my willingness to take full financial responsibility for any and all medical services rendered and thus release AWANA Clubs International and Salem Baptist Church from this liability.

This consent will be exercised only after a reasonable effort has been made to contact the emergency contact person as listed on the registration form.

_________________________________________________
(Child’s Name)

_________________________________            ________________
Signature of Parent/Guardian                    Date

_________________________________    
Print Name

MEDICAL INFORMATION

Name of Physician        ______________________________

Physician Phone Number    ______________________________

Insured Designated Hospital    ______________________________

Insurance Company        ______________________________

Policy Number        ______________________________

Expiration Date         ______________________________

Date of last DPT or Tetanus    ______________________________

Allergies of child/chronic illnesses/other conditions:  _____________________________  
    __________________________________________________________________
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