It is with my full knowledge and permission that my son/daughter/ward, _________________________, whose birthdate is __________________participates in church sponsored activities of Christ the King Lutheran Church, 1600 N. Genesee Street, Delafield, WI, 53018, during the period commencing from the date below. I hereby authorize the youth group leadership [as designated and empowered by Christ the King Lutheran Church] to consent, on my behalf, to such examination of my child by a licensed physician as is necessary to determine the nature and extent of any injuries or illness, including but not limited to the taking of x-rays and body fluids, and s/he is further authorized to consent to such treatment as such physician determines to be reasonably necessary under the circumstances except for those treatments, if any, listed below. I further authorize said person(s) to sign any consent forms required by any hospital as a condition to the examination or treatment by a physician and/or duly recognized member of a hospital staff. I understand that treatment may begin prior to my awareness of the situation, but I expect to be notified at the earliest time which is reasonably possible under the circumstances. This authorization expires when my child separates from the League, turns 20 years of age, or on 9-30-2008, whichever comes first.

Exceptions: _______________________________________________________________________
_______________________________________

Medical Insurance Company - name & number: __________________________________________
_______________________________________

Primary Care Physician - name & telephone: ____________________________________________

Signed     _______________________	Date_________________
Address   _______________________	City __________________
Telephone ________________= home
________________ = home
________________ = work
________________ = summer
________________ = cell

Please indicate any pertinent medical information -- (allergies, medications taken, contacts, etc.)
__________________________________________________________________________________
__________________________________________________________________________________

It is with my full knowledge and permission that my son/daughter/ward, _________________________, whose birthdate is __________________participates in church sponsored activities of Christ the King Lutheran Church, 1600 N. Genesee Street, Delafield, WI, 53018, during the period commencing from the date below. I hereby authorize the youth group leadership [as designated and empowered by Christ the King Lutheran Church] to consent, on my behalf, to such examination of my child by a licensed physician as is necessary to determine the nature and extent of any injuries or illness, including but not limited to the taking of x-rays and body fluids, and s/he is further authorized to consent to such treatment as such physician determines to be reasonably necessary under the circumstances except for those treatments, if any, listed below. I further authorize said person(s) to sign any consent forms required by any hospital as a condition to the examination or treatment by a physician and/or duly recognized member of a hospital staff. I understand that treatment may begin prior to my awareness of the situation, but I expect to be notified at the earliest time which is reasonably possible under the circumstances. This authorization expires when my child separates from the League, turns 20 years of age, or on 9-30-2008, whichever comes first.

Exceptions: _______________________________________________________________________
_______________________________________

Medical Insurance Company - name & number: __________________________________________
_______________________________________

Primary Care Physician - name & telephone: ____________________________________________

Signed     _______________________	Date_________________
Address   _______________________	City __________________
Telephone ________________= home
________________ = home
________________ = work
________________ = summer
________________ = cell

Please indicate any pertinent medical information -- (allergies, medications taken, contacts, etc.)
__________________________________________________________________________________
__________________________________________________________________________________