213 W. Curtis St.
Simpsonville, SC 29681

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864.963.5834

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As a parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the above minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

This release will cover any and all outings and events my child will go on with the Temple Baptist Church. My signature also indicates my willingness to take full medical insurance responsibility for my son/daughter and to release Temple Baptist Church from this liability.