As the parent or legal guardian of minor child[ren] participating in events/activities sponsored by First Brethren Church of North Manchester, I hereby give permission to medical personnel selected by the church designee to order X-rays, routine tests and treatment for my minor child[ren]. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to my minor child[ren].

I further authorize the release of the above medical information to the church designee, appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity.

I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury.

This Emergency Authorization is good for the one-year period beginning July 1, 2021 and ending June 30, 2022.

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