AUTHORIZATION FOR
EMERGENCY MEDICAL CARE
I, being the mother/father/legal guardian of ______________________________, a
minor, do hereby authorize Connie Belmore, or designee, as representative of the Trinity
United Methodist Church of Jacksonville, North Carolina to authorize emergency
medical care, should it become necessary, for my minor child.
This authorization shall remain in full force and effect for one year from and
after the date of execution of this document.
_______________________________
Date: ____ / ____ / 20____
(Signature of Parent / Legal Guardian)
_______________________________
(Printed or Typed Name of Parent / Legal Guardian)
Insurance Company: __________________________________
Name of the Insured on Policy: ______________________
Policy Number: ______________________
Insurance Company Phone Number: __ (____) ____ - __________
Home Phone Number: __ (____) ____ - __________
Other Emergency Phone Number: __ (____) ____ - __________
Please include a photocopy of the insurance card, front and back.
North Carolina, Onslow County
Signed before me this day by __________________________(Name of parent/guardian).
Witness my hand and official seal, this the ______ day of ________________, 20____.
Official Seal:
______________________________
Official Signature of Notary
___________________, Notary Public
Notary’s printed or typed name
My Commission Expires:__________
<< Please complete reverse side>>
Trinity S.O.U.L. Ministries
Youth _________________________
Grade _________
Age ___________
Please check any condition listed below that affects your child:
Y N
Y N
  ADD/AHD
  Heart problem
  Asthma ________ (date of last attack)   Kidney/Urinary problem
  Birth Defect
  Migraines
  Blood Disorder
  Muscle/Bone problem
  Cerebral Palsy
  Missing organ/Transplant
  Cystic Fibrosis
  Seizures ________ (date of last seizure)
  Diabetes
  Sickle cell disease (not trait)
  Hearing Problem
  Vision problem (Wears glasses? Y/N)
  Other Conditions (list below)
Please write a brief description of any “yes” answers. Use back of this page if necessary.
Is there any reason that your child’s activity should be restricted?  Yes (explain)  No
Allergic to:
Type of Reaction: (Circle)
Food: _________________________ Breathing Problems Rash/Hives
Swelling Vomiting
Medicine: _____________________ Breathing Problems Rash/Hives
Swelling Vomiting
Insect Bites/Stings: ______________ Breathing Problems Rash/Hives
Swelling Vomiting
Other: ________________________ Breathing Problems Rash/Hives
Swelling Vomiting
If your youth has an allergic reaction, are there specific instructions to follow in treatment?
List medicines that your child takes at home and the reason:
List medicines or medical procedures that your child will require at events and the reason:
Are there custody arrangements of which we should be aware?
Parent Signature: ________________________________
Date: _____________________
<< Please complete reverse side>>