WORTHINGTON UNITED METHODIST CHURCH614-885-5365
Worthington United Methodist Church
600 High Street
Worthington, OH 43085
614-885-5365
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Medical / Emergency Authorization Form
Worthington United Methodist Church

Name of Participant:


Address: Birth Date of Participant:

Hospital Insurance:   Yes   NoName of Insurance Company:

Name of Family Physician:Phone #:

Name of Family Dentist:Phone #:

List of Known Drug Allergies:


List of Known Food or other Allergies:


List of any Medications taken routinely:


List of Physical Limitations of Participant:


Other:

We (I) hereby give permission to the medical personnel selected by the Worthington United Methodist Church staff to order X-rays, standard tests, and treatment for me or my youth, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Worthington United Methodist Church staff to hospitalize, secure proper treatment, and give permission for emergency surgery, medical treatment, and anesthesia for me or my youth as named above and assume the responsibility of all medical bills, if any.

We (I) hereby verify that the participant on the event has had a current tetanus shot and can engage in all activities except those noted above. This form may be photocopied.

Parent/Guardian Signature:Date:

Home Phone:Cell Phone:

Name of Emergency Contact other than yourself::

Relationship:Phone #:


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