Community Bible Chapel
Monday, August 26, 2019
A place to grow.... where everybody is somebody and Jesus Christ is Lord.
                                        Community Bible Chapel Emergency Consent Form

I;  being the parent or guardian, authorize the administration of emergency medical treatment to s/he who is subject to consent to any emergency medical treatment necessary for the safety of the subject of this form.  I
understand all reasonable safety precautions will be taken at all times and neither said adult worker nor Community Bible Chapel may be held personally or corporately liable.

Name__________________________________Date of Birth___________SS#_____________

Address_______________________________________________  Phone #________________

Medical Insurance Co.______________________________Policy & Group #_______________


Person To Contact In Case Of Emergency________________________Phone #____________

Parent of Guardian Signature_______________________________