Name _______________________________________SS# ____________________________

Street Address ________________________________________________________________

City __________________________________Zip___________________________________

Name of Doctor ______________________________________________________________

Street Address _______________________________________________________________

City __________________________________Zip __________________________________

Phone _____________________________________________________________________

List any allergies to medication __________________________________________________

Are you taking any medication regularly? ________Name of Medication _________________

Date of last tetanus immunization ________________________________________________

Do you wear contact lenses? ____________________________________________________

I hereby give my permission for the above minor to be given any necessary X-ray, examination, anesthetic,
 medical, or surgical treatment under the supervision of any physician or surgeon licensed under the Medical
Practice Act. This authorization is given pursuant to the provisions of Section 2 of Act 116 of Public Acts 1973
(MCL) and after a reasonable attempt has been made to contact parents or guardians,

Signature of parent or guardian _________________________________________________

Home phone ______________________Work phone _______________________________

I give ____________________________________________permission to attend outings and trips with
 St. Paul Lutheran Church.

I also give permission for the above-named minor to travel to and from activities by way of any transportation
provided for those activities.

I further agree to release St. Paul Lutheran Church, its officers, pastor, Minister of Family Life, youth
counselors, or any other adults of responsibility in connection with this request.

Signature of parent or guardian _________________________________________________

Date ______________________________________________________________________

Insurance Company __________________________________________________________

Policy Number ______________________________________________________________