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Medical Consent Form

    I understand that every effort will be made to contact me. In the event medical care MUST be given for my child before I can be reached, or if I cannot be reached, I hereby give Good Samaritan Lutheran Church, Las Vegas, Nevada, permission to act on my behalf in seeking emergency medical treatment for my child, in the event such treatment is deemed necessary by the appointed representative of Good Samaritan Lutheran Church. I also give permission to those persons administering emergency medical treatment to do so using those measures deemed necessary, and to discuss the medical treatments and options with said representative from Good Samaritan Lutheran Church. I absolve Good Samaritan Lutheran Church, Las Vegas, Nevada, from liability in acting on my behalf in this regard, in so long as Good Samaritan Lutheran Church is not grossly negligent.

    Fields marked with * are required

    Name of Parent or Legal Guardian *

    Name of Youth *

    Youth Date of Birth *

    Street Address *

    State *

    Zip Code *

    Emergency Phone - Mother *

    Emergency Phone - Father *

    Alternate Person to Contact in the event neither of you can be reached in an emergency *

    Alternate Person's Phone number *

    Health Insurance Company *

    Ploicy # *

    Health Insurance Policy is in the name of *

    Is there any additional information we should know?

    Your Email *