PLEASE PROVIDE COPY OF FRONT AND BACK OF INSURANCE CARD

In the event that ____________________________________ becomes ill or sustains an injury while on an authorized and chaperoned event with SECOND PRESBYTERIAN CHURCH, LOUISVILLE, KENTUCKY, I, the undersigned, give my permission to those in charge to take whatever steps are necessary to stop any bleeding and/or to administer first aid.

I also consent to an X-ray examination, Anesthetic, Medical (or Dental) or Surgical diagnosis and treatment including invasive procedures and hospital care, as well as the administration of drugs or medicine to be rendered to my son or daughter under the general or specialized supervision and upon the advice of a duly licensed physician and/or surgeon.

I understand that this consent will apply to all emergency situations present and future in effect until written revocation is made.

I also assume responsibility for any medical and emergency expenses in the event of accident, injury, or other incapacity, regardless of whether I have authorized such expenses.

The purpose of this rest of the form is to provide appropriate information to aid the adult sponsors in caring for your child on this trip. It will also be used to provide a doctor, clinic or hospital with appropriate information should the need arise.

Please list any injuries (broken bones, strains, etc.), illnesses (flu, etc.) or surgeries that have occurred over the past three to six months:

Please list any allergies of which we should be aware including allergies to any medicines:

Please list any and all medication that the participant will have with them on the trip including prescription and over the counter medication. (Yes, even Tylenol!)