New Hope Christian Church Youth
Medical Authorization Form
Please print form, fill out completely, sign and return to church prior to your child's participation in
off-campus activities.
Participant’s Name: ____________________________ Date of Birth ____/____/_____ Sex ____
Street Address: _________________________________ Age: _______Grade: ______
City: ___________________ State: ______ Zip: _________Email:_______________________
Home phone: ___________________Cellphone:________________________
Allergies/ special health concerns/ medications/ dietary needs:
____________________________________________________________________________
____________________________________________________________________________
Date of last tetanus shot: _____/_____/______
Surgery or serious illness history:
______________________________________________________________
Physician’s name: _______________________ Phone:__________________
Insurance Company: _____________________Insured’s name:___________________________
Policy number: ________________________ ID number: _______________________________
Parents: My child may participate in activities/events with the New Hope Christian Church Youth
Group, including travel during activities/events via church vehicle or automobile driven by an adult
chaperone/leader who is age 21 or older with a valid driver’s license. I give permission for my
child/myself to receive emergency medical care if necessary. I give the adult chaperones/leaders the
authority to act on my behalf with respect to my child’s/my own health and safety while at
activities/events, with the understanding that I/emergency contact listed below will be contacted as
soon as possible should the need arise. I accept full responsibility for any expenses for medical
treatment for my child/myself. I release New Hope Christian Church and its representatives, staff,
and volunteers from liability in the event of accidental injury or illness.
Effective for 6 months from __________________to________________.
Signed________________________________ relationship to participant _______________
Date ___________
(Parent/guardian or adult participant age 21 or over)
Print name: ________________________________
Emergency contact: __________________________phone#_________________