аЯрЁБс>ўџ -/ўџџџ,џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС5@ №ПwbjbjЯ2Я2 $ ­X­Xoџџџџџџˆnnnnтттіккккю,іцю& & & & & } } } egggggg$дR&Ž‹тЋy } ЋЋ‹nn& & S ЋnR& т& eЋe"1Р"т1&  а‘Ў–I3ЦкС.1eЖ0ц1ДяД1ііnnnnДт14} ЪG з tK`} } } ‹‹ііфкџіікMedical Release and Permission Form I give my consent for West Houston church of Christ trip sponsors to administer various medicines. Also authority is hereby granted to West Houston church of Christ trip sponsors to (1) release a copy of this health record to a medical doctor in the case of emergency and (2) place my child in the care of a legally qualified physician, surgeon, dentist, hospital, and/or designated professional when in their opinion it is necessary or best. I further hereby authorize any legally qualified physician/surgeon/hospitals to perform and/or furnish emergency medical treatment, surgery, medicine, equipment and services as, in their opinion, may be required. I hereby release West Houston church of Christ, its sponsors, staff, elders, or representatives from any and all liabilities of any kind and nature arising out of or in connection with the placing of said physician/surgeon/hospital, and I hereby agree to pay the reasonable costs of such treatment, surgery, medicine, equipment and services so provided. In addition, I _____ do allow/ _____ do not allow photos of my child taken at church events to be used in church publications and/or presentations. Child’s name: Child’s Age: ____________________________ Date of Birth: Child’s Allergies: Date of last tetanus booster: Child’s Physician’s Name: Phone: Physician’s Address Insurance Company: Policy or Group Number: Mother’s/Guardian’s Name: Address: Home phone: Cell phone: Work phone: Father’s/Guardian’s Name: Address: Home phone: Cell phone: Work phone: Parent/Guardian Signature Date State of Texas County of Before me, the undersigned, on the day personally appeared , and acknowledged to me that he/she/they executed this instrument for the purposes stated. Given under my hand and seal of office on this day of , 20 Notary Seal or Stamp Signature of Notary $ , 4 < H Ћ Ќ Н ш e З Э (-LMehiІЇ@ѕъпгпгпФЙЊ›Й››€€›Ф›ФujZjRjФhk CJaJhд)~hŠ&Э6CJOJQJaJhд)~hŠ&ЭCJaJhд)~hŠ&ЭCJaJhд)~hk CJOJQJaJhk CJOJQJaJhд)~hŠ&ЭCJOJQJaJhд)~hЬB CJOJQJaJhд)~hŠ&ЭCJaJhд)~hŠ&ЭCJOJQJaJhд)~hд)~5CJaJhд)~hд)~CJaJhд)~hŠ&ЭCJaJhд)~hŠ&ЭCJ"aJ"$р Е  Ћ Ќ Н ј - P e y ’ ­ З §љѕѕѕ№сбХсГЃ““““ ЦаР!„аdhЄ ^„а$ ЦаР!„Є ]„a$$ Ц аœР!„Є ]„a$ ЦаР!dhЄ  ЦаР!„аdhЄ `„а$ ЦаР!dhЄ a$$a$ЄxЄ№ovўўЗ а н ј ()-LMhэнннэнаПВЉ|- Ц€$„$d %d &d 'd NЦџ OЦџ PЦџ QЦџ ^„$„а^„аa$ $ ЦH„*^„*a$$ ЦарHР!„а^„аa$ $ ЦР!„а^„аa$ ЦаР!„аdhЄ ^„а Ц арР!„аdhЄ ^„а hiІ>?@иЉЉ…Z……* Ц ЬJ"$d %d &d 'd NЦџ OЦџ PЦџ QЦџ #$d %d &d 'd NЦџ OЦџ PЦџ QЦџ .$ Цм#„$d %d &d 'd NЦџ OЦџ PЦџ QЦџ ]„a$&$$d %d &d 'd NЦџ OЦџ PЦџ QЦџ a$@ABFopqrstдА…VTTTTT.$ Ц„$d %d &d 'd NЦџ OЦџ PЦџ QЦџ ^„a$* Ц x$$d %d &d 'd NЦџ OЦџ PЦџ QЦџ #$d %d &d 'd NЦџ OЦџ PЦџ QЦџ *$„$d %d &d 'd NЦџ OЦџ PЦџ QЦџ ^„a$ @AFZqrstuvwѓфиЭТЭТЭТЭhд)~hŠ&ЭCJaJhд)~hŠ&ЭCJaJhд)~hŠ&ЭCJ]aJhд)~hŠ&ЭCJOJQJaJhд)~hŠ&Э6CJaJ tuvw§§Ю.$ Ц„$d %d &d 'd NЦџ OЦџ PЦџ QЦџ ^„a$":pЬB Аа/ Ар=!А "А #а$–%Аœ8@ёџ8 Normal_HmH sH tH N@N Heading 1$$„а@&^„аa$ 6OJQJP@P Heading 2$$„а@&^„аa$56OJQJ@@ Heading 3$@& CJOJQJ@@ Heading 4$@& CJOJQJDAђџЁD Default Paragraph FontViѓџГV  Table Normal :V і4ж4ж laі (kєџС(No List <B@ђ< Body Text$a$OJQJTT@T Block Text$„v„аdh]„v^„аa$OJQJHP@H Body Text 2$„а]„аa$OJQJB>@"B Title$a$5CJ$OJQJ\^Jwџџџџџџџџџџџџ џџw џџџџ$рЕЋЌНј -Pey’­Занј()-LMhiІ>?@ABFox˜0€€˜0€€˜0€€p˜0€€˜0€€p˜0€€˜0€€˜0€€˜0€€˜0€€ˆ˜0€€˜0€€ˆ˜0€€ €˜0€€ˆ˜0€€ €˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€ €˜0€€˜0€€ ˜0€€ €0€€˜0€€ ˜0€€˜0€€˜0€€ €˜0€€€˜0€€ €˜0€€0€€(˜0€€˜0€€ €M90€M90мœ@wЗ h@tw v №А№ƒ №p0e‚˜Вƒ0e„˜В…‡ˆ‰П є   РСТџџџУ ФХAЦСЧШЩЪЫ5%ЬЭЮЯСабвгдезџ€€€ЫЫЫ 8c8c     ?€‚ƒœ1„…№љ†‡їˆ ПРСТdУФХЦЧШЩЪ0uЫаЬ0эьџЭ@T‰Ю€Я€џџаyџб2в NгPУде'жp”зА<џџий'кp”џAЈ)BCD|ОE„|О…†|О‡@ёџџџ€€€ї№’№№0№( № №№B №S №ПЫџ ?№wџџЬНл Downloads