Medical Permission for Durham Friend’s Meeting Youth Group

Date: __________________________

Child’s Name: __________________________________________________________________________________

Parent’s Name:_________________________________________________________________________________

Address: ______________________________________________________________________________________

______________________________________________________________________________________

Phone: ________________________________________________________________________________________

Emergency Contact #1

Name: ________________________________________________________________________________

Address: ______________________________________________________________________________

______________________________________________________________________________

Phone: ________________________________________________________________________________

Emergency Contact #2

Name: ________________________________________________________________________________

Address: ______________________________________________________________________________

______________________________________________________________________________

Phone: ________________________________________________________________________________

Doctor Information

Name: ________________________________________________________________________________

Address: ______________________________________________________________________________

______________________________________________________________________________

Phone: ________________________________________________________________________________

Insurance Company: _____________________________________________________________________

Policy Number: _________________________________________________________________________

I.D. Number: ___________________________________________________________________________

Please list special medical concerns (allergies or special medical conditions) on the back of this form.

I _______________________________________________ give permission for my child to participate in the activities

of the Durham Friend’s Meeting Youth Group.

Signed: ________________________________________________ Date: __________________________

I, as parent or legal guardian, do hereby grant the designated adults of the Durham Friend’s Meeting the right to authorize emergency medial

treatment for my child named above in the event that I cannot be reached. I agree to hold harmless Durham Friend’s Meeting and it’s agents

from liability arising out of an accident situation. The North Carolina Good Samaritan Law will apply.

Signed: ________________________________________________ Date: __________________________