NEW LIFE COMMUNITY CHURCHPRIOR CONSENT AND EMERGENCY TREATMENT OF MINORS

I/We, the undersigned mother, father or legal guardian of the below-named minor, herebyauthorize and consent to the attendance of said minor to the functions of and to travel in privatevehicles with any event sponsored by:New Life Community Church8155 West Thunderbird RoadPeoria, Arizona 85381623.486.3737I/W e hereby request, authorize and give my consent, in the event all reasonable attempts tocontact me or my spouse or other guardian's named below have been unsuccessful to:1) The administration of any medical treatment deemed necessary by the below-namedphysicians, or, in the event the appropriate preferred below-named practitioner is not available,by another duly licensed physician or dentist; and2) The transfer of the below-named minor to any reasonably accessible hospital and suchexamination, treatment, and medical attention as may be determined necessary by theemergency room doctors at such facility or by other appropriate licensed physicians or dentists.In conjunction with this authorization for medical treatment, the following information isprovided for utilization by any hospital or practitioner not having access to my child's medicalhistory:

(PRINT IN INK)

Child's Name_________________________________ Birth Date_______________________Father's (or Legal Guardian) Name_____________________ Home Phone________________Home Address________________________________ City__________________ State______Employed by__________________________________ Work Phone ____________________Mother's (or Legal Guardian's) Name____________________ Home Phone_______________Home Address_____________________________ City_________________ State _________Employed by__________________________________ Work Phone ____________________