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Medical Power of Attorney/Liability Release Form and Medical/Insurance Information
Pleasant Hill Presbyterian Church
3700 Pleasant Hill Road
Duluth, GA 30096
770-497-0233

I do hereby extend and grant full authorization and power of attorney to the Rev. Jennie Sankey, Associate Pastor for Christian Education; Youth Group Advisers; or other designated adult event coordinators in attendance of Pleasant Hill Presbyterian Church for the purpose of: obtaining, permitting and authorizing medical and/or dental care and treatment, including surgery, and any other necessary medical or dental procedures, for an on behalf of my child while on an authorized activity with Pleasant Hill Presbyterian Church and such person or persons shall be full authorized and have full power of attorney on behalf of the undersigned to execute any and all consent forms, admission papers and any other documents attendant to procuring such necessary medical or dental care and treatment.

In addition, I hereby release Pleasant Hill Presbyterian Church, its staff, employees and volunteer leaders from any and all liability or from any and all claims, demands or causes of action related to injuries sustained by minor(s) during any authorized activity with Pleasant Hill Presbyterian Church.

This release and power of attorney shall be in full force and effect from August 22, 2021 through August 31, 2022.

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Insurance Group Number

Insurance Phone Number

Medical Conditions and Prescriptions (medicine prescribed by a doctor, i.e. pain, chronological illnesses, mental health, allergies, etc.)

Medical Conditions and Non-Prescriptions (over the counter medicines for common cold, headaches, stomachaches, motion sickness, low blood sugar i.e. Advil, Claritan, glucose, Tums, etc.)

Special Requirements (Dietary needs, i.e. Food allergies, vegetarian, vegan, lactose intolerant, gluten free, diabetic, hypoglycemic, etc.)
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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