RELEASE AND CONSENT TO MEDICAL TREATMENT

STATE OF TEXAS

COUNTY OF COLLIN

I do hereby consent as parent or legal guardian of ________________________________to reasonable and necessary medical treatment in the event of the necessity therefore, and I hereby authorize the First Baptist Church of McKinney, through its employees, agents and volunteers, to provide such consent to any health care provider that may require it, sign necessary papers, and in general arrange for reasonable and necessary medical care and treatment that may be necessary.

            I further release and forever discharge the First Baptist Church of McKinney, its employees, agents and volunteers of and from any and all claims, demands, damages, actions, causes of action, negligence or suits of any kind or nature, whether heretofore or hereafter accruing, and whether not known, arising out of any activity of the First Baptist Church of McKinney in which my child is a participant.

            This Release and Consent shall be valid and binding until revoked by me, in writing, delivered to Grant Byrd, First Baptist Church of McKinney, Texas.  I acknowledge that I have read and understand the effect of this Release and Consent to Medical Treatment, and I am executing it for the purposes and considerations set forth.

_______________________________

Parent or Guardian

Dated this __________ day of _______________, 2006.

Insurance Information:

Carrier: ________________________________________________

Group Number: _________________________________________

Policy Number: _________________________________________

Telephone number of Insurance Company: ___________________

AWOL Latvia 2006

Contact Form

Name:

Last ______________    First __________  Middle _____

Age: ____                Date of Birth  ___________

Male  ___     Female  ___          

Address:     ________________________________

                         City _____________  St. ___  Zip ______

Parent or Guardian Name: ______________________­_

Phone:   Home  _____________   Work ____________     

                           Cell    _____________

Email ________________________________________

Any special requirements or attention needed: ________

_____________________________________________

Health related information:  _______________________

_____________________________________________

Dietary restrictions: _____________________________

Current medication (send with instructions): __________

_____________________________________________

Reason for taking above medication: _______________

_____________________________________________