This information is correct as far as I know, and the person herein described has permission to engage in all Birmingham United Methodist Church Student Ministries related activities except as noted.
I hereby give permission to the medical personnel selected by the staff of Birmingham United Methodist Church to order X-rays, routine tests, treatment; to maintain and/or release any medical records necessary for insurance purposes; and to provide or arrange necessary related transportation for me or my child. In an emergency, I hereby give permission and authorize the physician selected by Birmingham United Methodist Church Student Ministries to secure or administer emergency medical treatment, including hospitalization and any other emergency medical procedures which may be needed for the person named above. I authorize the physician or dentist to call in any necessary consultants in his/her discretion. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise their best judgment as to the requirements of such diagnosis or medical, dental or surgical treatment. I agree to remain fully liable and responsible for the payment of any such hospital, doctor, ambulance, dental or medical fees. I further agree that in giving this permission and authorization, Birmingham United Methodist Church do not assume any responsibility or liability for the payment of such hospital, doctor, ambulance, dental or other medical fees which may be incurred. The completed forms may be photocopied and maintained by authorized personnel. This form, both front and back, is valid by my permission through December 31, 2018.