2721 164th Street SW, Lynnwood, WA 98037
Phone: (425) 743-2592
Fax: (425) 745-5712
E-mail: mlcc@marthalakecov.org
http://www.marthalakecov.org/awana.htm
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Martha Lake Covenant Church 2721 164th Street SW, Lynnwood, WA 98037 Phone: (425) 743-2592 Fax: (425) 745-5712 E-mail: mlcc@marthalakecov.org http://www.marthalakecov.org/awana.htm |
Awana Club Activity Permit
To Whom It May Concern:
As a parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the following minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.
Name of Minor _____________________________
This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment with emergency circumstances in my absence.
Signature ______________________________ Date _________________
q Father q Mother q Legal Guardian
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Phone number(s) |
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| Full Address |
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| Physician name & phone number(s) |
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Specific medical drugs, chronic illness, or other conditions: |
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Date of last tetanus shot _________________________
Other contact in case of emergency: Relationship ________________________________________________
| Name |
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Phone number(s) |
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| Return to the MLCC home page | Awana main page | Awana forms list | MLCC Form 101 (2002-09-03) |