Youth Medical Treatment Form Youth Permission Form Name of Child(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Name of Parent/Guardian(Required) First Last Name of Parent/Guardian First Last Address(Required) Street Address Address Line 2 City State ZIP / Postal Code Phone(Required)Emergency Contact Information(Required) First Last Relationship to Child(Required) Phone(Required)Child's Health InformationPlease provide any and all information regarding special circumstances, medical history, allergies, penicillin or drug reactions, etc., while on event and which caretakers and/or providers should be aware about.Insurance Company(Required) Policy Number(Required) Permission to Treat My Child(Required) I agree with the following understanding of First Presbyterian's role in the medical care of my child.In the case of emergency, I understand that every effort will be made to contact me. However, if I cannot be reached, I hereby give First Presbyterian Church, its employees and agents permission to act on my behalf in seeking medically necessary treatment for my child. I give permission to those administering medically necessary treatment to do so, using those measures deemed necessary. I absolve and hold harmless First Presbyterian Church from any and all liability in providing for such treatment and/or acting on my behalf in this regard.Signature(Required)Type your name as an electronic signature. Date(Required) MM slash DD slash YYYY
