I,
The undersigned parent or guardian of ___________________,
give my son/daughter permission to participate in the River Hills Youth
Events.
I, the undersigned parent or guardian of ____________________, a minor, do hereby authorize adult workers with the youth of River Hills UMC to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under the supervision of any physician or surgeon licensed hospital, whether such diagnosis or treatment is rendered at the office of said hospital or at said hospital.
Insurance
Company or Group: _____________________________
Policy
Number: _________________________________________
Any
Allergies? Special Needs? _____________________________
Name
of Participant: _____________________________________
Parent
or Guardian: ______________________________________
Address:
_______________________________________________
City:
____________________________Zip:___________________
Daytime
Phone: _________________Evening Phone: _________________
Signature of Parent or Guardian Date: