MEDICAL INFORMATION AND RELEASE

YOUTH'S NAME: __________________  BIRTH DATE: ___/___/___

ADDRESS: _______________________  PHONE: ________

                  __________________________

Mother's Name: ___________________  Work Phone: _____________

Father's Name: ____________________  Work Phone: ____________

Person to contact if
you cannot be reached: _____________________   Phone: ___________

                                              ________________________________

I (we), the undersigned, parent (s)/legal guardian (s) of _______________, a minor, do hereby authorize the Pastor and Sponsors of Incarnation Lutheran Church to be agents for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered under, the general or specific supervision of any surgeon or physician, licensed under the provisions of the Medical Practice Act, on the medical staff of any accredited hospital, whether such diagnosis is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid treatment, or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable.

It is further understood that all reasonable effort will be made to get in touch with parent (s) /legal guardian (s) prior to the use of authorization.

MEDICAL INSURANCE COMPANY NAME: ______________________

POLICY # _____________________    GROUP # _________________

PARENT SIGNATURE: ____________________   DATE: __________