Insurance Form and Permission

Today's Date

Parent/Guardian's Name

Hereby authorize the staff of the the Heights International Ministries, South Canonsburg Church, Evangelization Society or the Church at the Heights to give consent for emergency medical treatment of:

Nme of Insured (child or dependent)

This authorization will be valid from:

Starting Date of Event

through

Ending Date of Event

Insurance Information

Name of Insurance Company

Insurance Policy Number

Group Number

Name of Person Holdiing the Insurance Policy

By signing this I have read the enclosed information and hereby give my child permission to attend this event. I also authorize the staff to seek medical attention on behalf of the above child/dependent.

Type Your Signature Here

You MUST check this button to verify the information above

Verify MY CONSENT

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