Old Presbyterian Meeting House: Home: Parent Release and Emergency Contacts

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Parent Release and Emergency Contacts The Meeting House Youth Group has my permission to provide child care for my children on Friday, March 5 from 6:30-9:00 pm at the Old Presbyterian Meeting House. * Required Child's full name/Nicknames/Age/School Grade * Parent/Guardian Names (First, Last) * Address Line 1 * Address Line 2 City * State * ZIP Code * Phone Number * Cell Phone Number * Physician to contact in case of emergency: (name) * Physician phone number: * People authorized to pick up child in case of emergency and parent/guadian cannot be reached: 1. Name/phone/relationship 2. Name/phone/relationship Persons NOT AUTHORIZED to pick up my child/children Authorization for Emergency Treatment In case of emergency, I understand OPMH Youth Group (Child Care Provider) will make every effort to contact me. In the event I cannot be reached, I hereby give my permission to an adult in charge to take my child to the nearest emergency medical facility. The licensed health care practitioners are authorized to treat my child as deemed medically necessary for the well being of my child. I agree to accept all financial responsibility for medical expenses. * Medicines my child/children are taking: * Allergies: * Special Information: Insurance Company Information: * By typing my name in the following box I certify the above statements to be true and correct * Parent/Guardian Signature and Date
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Old Presbyterian Meeting House

323 South Fairfax Street, Alexandria, VA 22314

703-549-6670