AUTHORIZATION FOR TREATMENT OF A MINOR CHILD

_____________________,  Hereby authorize the staff of the Evangelization Society, and

          (Parent’s Name)

Church at the Heights to give consent for emergency medical treatment of:

_________________________________ in my absence.

          (Name of Child or Children)

This authorization will be valid from _________________ to ____________________.

                                                                 (Starting Date)                   (Ending Date)

My Insurance Information:

INSURANCE COMPANY:_________________________________

GROUP NUMBER:_______________________________________

POLICY NUMBER:_______________________________________

NAME OF INSURED:_____________________________________

CHILD’S DATE OF BIRTH:________________________________

______________________________________                         

                   (Signature of Parent)

______________________________________

                    (Signature of Witness)

By signing this I have read the enclosed information and hereby give my child permission to attend.