MEDICAL INFORMATION AND AUTHORIZATION FORM

Together Building Bridges

U.C.C. New England Women’s

Celebration VIII

March 12-14, 2010

To be completed for all youth participants.

PLEASE PRINT

I request and authorize the staff of the Together Building Bridges U.C.C. New England Women’s Celebration VIII to secure, if necessary, medical assistance for my child. The name of the youth covered by this authorization is:

Name _________________________________________________________________

(First) (Middle) (Last)

Date of birth (month/day/year): ________________

Parent/Legal Guardian ___________________________________Phone number(s)____________________________

In case of Emergency, additional contact:

Name___________________________ Phone number(s)______________________

Health Care Information

Do you carry family medical/hospital insurance? YES______ NO_____

If so, indicate: Carrier ____________________ Policy/Group #_________________

Health information we should be aware of:

________________________________________________________________________

Signature of Participant: ____________________________________Date________________________________

Signature of parent/guardian (if participant is under 18 years old):

_____________________________________________________Date_______________