Medical Release and Authorization
As Parent and/or Guardian of son/daughter, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the said person, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of his/her life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.
Permission is granted to the attending physician to proceed with any treatment for the named person. In the event of an emergency, I understand that every attempt will be made by the attending physician to contact me. This authorization is granted only after a reasonable effort has been made to reach me.
Permission is also granted to Five Stones Church to provide the needed emergency treatment prior to his/her admission to the medical facility.
This release is authorized of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb in my absence.