Norwalk Alliance Church

Cross-eyed Youth Ministry

Emergency Medical Consent Form

I, _____________________ as parent/legal guardian of _________________________, hereby authorize Pastor Wayne Mushett or his staff to obtain medical treatment for my child in event of an emergency occurs while traveling to and from and during their trip to _________________________. Below is our health insurance information and personal information to contact us during the trip.

My telephone numbers are:

Home: ( ) ____ - ________ Work: ( ) ____-_________

Additional Contact Number(s): ( ) ____-__________ ( ) ____-___________

My child is covered under the following Insurance Plan:

Company: _____________________ Policy Number: _____________________

I.D. Number: ___________________ Telephone Number: __________________

___________________________________ __________________________

(Signature of Parent/Legal Guardian) (Signature of Student)

___________________________________ __________________________

(Date) (Date)

Permission Release Form

I, _____________________ as parent/legal guardian of ________________________, hereby grant permission to Wayne Mushett and his staff to escort my child to and from on their trip to _________________________on _________________________.

___________________________________ __________________________

(Signature of Parent/Legal Guardian) (Signature of Student)

___________________________________ __________________________

(Date) (Date)

***The original will accompany the Youth Pastor and a copy will be kept for the Church file.***