___________________________________________  __________________
Child's Name                                                                    Date of Birth 

________________________  __________________  _________    _______
Address                                      City                               State               Zip  

_________________________  _________________  ___________________
Parent or Guardian Name              Home Phone                Work Phone

_________________________  __________________
Insurance Company                       Policy Number                  

Allergies:________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
 
 

I hereby authorize the treatment, administration of anesthesia, surgical treatment(s) for my minor son/daughter in the event of a medical situation occurring during my absence or when the hospital or physician(s) are unable to contact me.  This authorization extends to any hospital physician and nursing personnel within the physician(s), and nussing personnel for performing medical procedures acting on the authority of this medical treatment consent form which such medical providers deem necessary for my minor child.

Signed this ___________ day of  _______________, 2005.

_________________________________________
Signature of Parent/Guardian

Special Medical Conditions/Other Necessary Health Information: 
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

The E-Bulletin is the weekly newsletter of Saint Michael's Church. It features articles on issues important to you as well as on events and issues affecting the community of Bradford, Indiana.