First Assembly of God

Emergency Treatment Permission Authorization Form

I/we, the undersigned parent(s)/guardian(s), hereby give permission for my child,

____________________________________, to attend and participate in all the following church-

sponsored trip(s) or activity(ies) with: First Assembly of God of Lathrop, MO,

which will take place on the following date/dates:  October 1, 2007 to October 1, 2008.

I/we also hereby give permission for the adult sponsors or chaperones in charge of the trips/activities

to seek medical treatment for my child, if I am not present and cannot be reached by telephone

in case of an illness or injury.

Authorization is also given to the adult sponsors or chaperones in charge of the trips/activities

to have my child admitted to and treated at the nearest or most convenient hospital if such

action is determined to be necessary.

I/we will be responsible for the charges for any medical treatment or hospitalization rendered as a result of this authorization.

Teen's Date of  Birth:

Blood Type:

Family Physician:

Phone Number:

Additional information that may be helpful in treating your teen: