ࡱ> (*'@  jbjbqq l Z,u b&&&& &&& M"&&Medical Release Form Community Christian Church Youth Ministries I,_____________________________ (Parent/Guardian's Name) hereby give permission for any and all medical attention to be administered to my child ____________________________ (Child's Name) In the event of accident, injury, sickness, etc., under the direction of the person(s) listed below and a representative of Community Christian Church, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. This release is effective for the period of one year from the date given below. ADDRESS: ________________________________________________________________ . ________________________________________________________________ HOME PHONE: _________________________________ INSURANCE COMP: _______________________________________________________________ POLICY NUMBER: _______________________________ In case I cannot be reached, any of the following persons is designated to act on my behalf. ________________Relationship___________ Phone ____________ ________________Relationship___________ Phone ____________ PHYSICIAN: ____________________________________________________________ PHONE: _______________________________________________________________ DATE OF LAST TETANUS SHOT: _____________________________________________________________ KNOWN ALLERGIES:____________________________________________________ SIGNATURE (PARENT/GUARDIAN) _______________________DATE ________ A  CJOJPJQJ5CJOJPJQJ0ABWX  9 : # $ _ ` , - 1$7$8$H$ & 0` P@0ABWX  9 : # $ _ ` , -  -  1$7$8$H$ & 0` P@#0/ =!8"8#$%|,,  % { g(,,(d'` i0@0NormalCJOJQJmH <A@<Default Paragraph Font  % z -   CE::RyanBWiz Bang:Users:mikesmith:Desktop:Mike's Stuff:Medical Release Form/-)-)@=  @GTimes New Roman5Symbol3 Arial7Courier3Times7Amphion"h{&{&A20s@Medical Release FormRyanRyan Oh+'0d   , 8DLT\'Medical Release Form 1ediRyanal yanNormal Ryanl 1anMicrosoft Word 10.1@0@@*  ՜.+,0 hp|  'CCC Medical Release Form Title  !"#$%&)Root Entry F%+1TableWordDocumentSummaryInformation(DocumentSummaryInformation8CompObjXObjectPool%% FMicrosoft Word DocumentNB6WWord.Document.8