We, the undersigned parents (s)/guardian(s) of

(Name of child)________________________________ (Date of Birth)_______/________/_________

Grade: ________ Please circle child’s activities: Fun With Faith Sunday School Confirmation High School Vacation Bible School

Address: ___________________________________________________Zip:___________________

Telephone Number (home):______________________Home E-mail address : _________________________

Do authorize hereby give permission to authorized representatives of Mount Cross Lutheran Church to authorize necessary emergency medical consultation, examination and treatment of the above named child, including the prescription of needed medications, in the event of accident, illness or other trauma at any medical facility. Information related to the care of this child can be obtained from

(Name of physician)______________________________

(Address) ___________________________________

(Phone Number)______________________________________

Medical Insurance information:

(Name of Company)____________________________

(Member Number) ______________________________

(Group Number)________________________________

Special information or instructions relating to medical conditions, allergies, medications, etc.:

________________________________________________

_________________________________________________

This authorization is to be in effect from September 1, 200__ until August 31, 200__

Signed by parent(s) or guardians(s)

Signature of father: ________________________ Signature of mother: ________________________

Print name:______________________________ Print name ______________________________

(Address) _______________________________ (Address) _______________________________

(Home phone)_______________________ (Home phone)_______________________

(Cell phone)________________________ (Cell phone)________________________

(Work phone)_______________________ (Work phone)_______________________

E-mail address : _________________________ E-mail address : _________________________

In case we cannot be reached at above numbers, please call:

(Name)___________________________________ (Relationship)__________________________

(Phone)__________________________________ (Cell phone)___________________________