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

Sunday Worship Schedule:
Fall/Winter/Spring Schedule:
Sunday September 11- May 21, 2012
8:30 am and 11:00 am
Communion at 8:30 am
Education for all ages at 9:40 am

Summer Schedule:
Sunday Morning
Sunday May 27 - September 2, 2012
10:00 am

Office Hours and Location
8:15 - 4:15, Monday - Friday
(Summer Office closes at 1:00 pm on Fridays)
323 South Fairfax Street
Alexandria, Virginia 22314-3716
Phone: 703-549-6670
Fax: 703-549-9425
Email: opmh@opmh.org

Taizé Service
The first Friday of the month,
7:00 pm in the Sanctuary.
Next service: March 2, 2012

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Beth Bathe

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Old Presbyterian Meeting House

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Parent Release and Emergency Contacts The Old Presbyterian Meeting House Emergency Contact and Medical Information for my child * Required Errors Meeting House Activity/Event and Date * 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 checking this box box I certify the above statements to be true and correct * Parent/Guardian Name and Date (serves as signature)
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Old Presbyterian Meeting House

323 South Fairfax Street, Alexandria, VA 22314

703-549-6670

The Old Presbyterian Meeting House

Emergency Contact and Medical Information for my child