Activity:______________________________________________  Date:_______________

Name: __________________________________ Social Security Number: _____-____-____

Address:__________________________  City_________________ St____   Zip___________

Phone: ______________  Age:______   Birth Date:  ____-____-____     Grade: _____ (6 - 12)

Are you a member of First Free Will Baptist Youth Group?      YES____      NO____

Medical Physician: ___________________________________  Phone: _________________

Insurance Provider:___________________________________ Ins No.__________________

List any current allergies, diseases, or other health problems:
____________________________________________________________________________

____________________________________________________________________________

List any regularly taken medications and Frequency:
____________________________________________________________________________

Father or Guardian Name__________________________     Phone (home)_______________

Employer: ______________________________________    Phone (work)_______________

Mother or Guardian Name__________________________    Phone (home)_______________

Employer: ______________________________________    Phone (work)_______________

In case of emergency and parent or guardian cannot be reached, please contact:

Name __________________________________________  Phone____________________

Health Care Power of Attorney

I/We, the parent(s) and/or legal guardian(s) of this youth member, a minor, do hereby authorize the youth leaders, staff, and/or chaperones acting in the capacity of activity supervisor, as my/our attorney-in-fact to act for me/us, in my/our name(s) in any way I/we could act in person, to make any and all decisions for me/us concerning the personal care, medical treatment, hospitalization, and health care of the minor above-named, in accordance with the terms of this health care power of attorney.

The above grant of power is intended to be as broad as possible so that attorney-in-fact will have authority to make any decision I/we could make in obtaining any type of health care.

This power of attorney will become effective the ______ day of ______________, 20___, and shall terminate the ______ day of ______________, 20___.

I/We am fully informed as to all of the contents of this form and understand the full impact of this grant of powers to my/our attorney-in-fact. I/We will not in any way hold attorney-in-fact, First Free Will Baptist church, it’s youth leaders, or chaperones accompanying in the trip liable in any way.

In witness whereof, I/we have executed this health care power of attorney in Church Hill, Hawkins County, Tennessee, on the date first set forth above.

______________________________________   

Parent / Legal Guardian