From: Subject: FIRST PRESBYTERIAN CHURCH Date: Mon, 31 Mar 2008 12:54:37 -0500 MIME-Version: 1.0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://fpccorinth.com/consentform.htm X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3028 FIRST PRESBYTERIAN CHURCH

FIRST PRESBYTERIAN=20 CHURCH

YOUTH HOUSE MINISTRIES

Parental = Consent/Medical=20 Treatment Form

Name of Church: First = Presbyterian=20 Church

Youth Leader: Gregg=20 Parker

I, the=20 undersigned parent of guardian of ______________________, a minor, = do

hereby=20 authorize adult workers with the youth of the above named church to =

consent=20 to any examination, x-ray, anesthetic, medical or surgical diagnosis=20 or

treatment and hospital care which is = rendered=20 under supervision of any

physician or surgeon licensed under = the=20 provisions of the Medical Practice Act

on the=20 medical staff of a licensed hospital, whether such diagnosis or=20 treatment

is=20 rendered at the office of said physician or at said hospital.

Further,=20 as parent or guardian of the minor named above, I do hereby = expressly

consent=20 that my son/daughter may receive emergency medical treatment = from

any=20 physician, hospital, or other medical center without the necessity of = first=20

notifying me, and do further agree = to hold=20 blameless any physician, hospital or

other=20 medical center for rendering such services.

Insurance = Company of=20 Group: ___________________________________________

Policy=20 Number:_______________________________________________________

(Please = print the=20 following information)

Name of = Participant:=20 _________________________

Parent or = Guardian:=20 __________________________

Address:=20 ______________________________________________________________

City:=20 _________________ State:_________ = Zip:______________________________

Daytime = Phone:=20 __________________ Evening Phone: _______________________

________________________________

(Signature of Parent=20 or Guardian)

My = signature confirms=20 that I hereby give witness to the proper completion of this

form by = the minor=92s=20 parent or guardian.