THE CHURCH IN GALLOWAY
1696 Ringfield Drive
Galloway, OH 43119
(614) 870-5354

PERMISSION FOR TREATMENT

Should my child be involved in any accident or incur any illness while accompanying representatives of The Church in Galloway, I hereby give my permission to any qualified physician to treat my child for such accidents or diseases as quickly as possible.
My child's name:  ____________________________________________

Address:

  ____________________________________________
 ____________________________________________

Home Phone:

  ____________________________________________

Work Phone:

  ____________________________________________

Hospitalization Insurance Comp:		  ____________________________________________

Billing Address:

  ____________________________________________
 ____________________________________________

Policy Number:

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Allergies or other medical information:		  ____________________________________________
 ____________________________________________

Signature of Parent/Guardian:		  ____________________________________________