Medical Authorization must be signed by parent or guardian.

NAME____________________________________________________

PARENT/GUARDIAN
FIRST & LAST NAME______________________________________

ADDRESS_________________________________________________

CITY____________________________STATE_____ZIP__________

EMERGENCY PHONE NUMBERS

Home_______________________ Cell_________________________

Work_______________________ Other_______________________

INSURANCE COMPANY___________________________________

POLICY NUMBER_________________________________________

IMPORTANT MEDICAL INFORMATION (ALLERGIES, ETC.)

_________________________________________________________

_________________________________________________________

My son/daughter has permission to attend Salem Youth activities. In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by the adult in charge to secure proper treatment for my child named above.

______________________________________ ___________
Signature Date
Salem Lutheran Church
70 E. Dayton St.
West Alexandria, OH 45381

Date ___________________________________

I give my permission for Salem Lutheran Church

Youth Representatives, or designated driver, to

transport my child _______________________________

to and from youth activities for the 2010 & 2011 calendar year.

______________________________________________
Parent's Signature