NORTH CAROLINA CONFERENCE OF TEMPLES AND COURTS

Ancient Egyptian Arabic Order Nobles Mystic Shrine

Of North and South America and Its Jurisdictions, Inc.

YOUTH’S EMERGENCY MEDICAL AUTHORIZATION FORM

This form authorizes emergency medical treatment for __________________________________________

(Child’s Name)

In case of injury in town or out-of-town trips, Parent(s) can be reached at

Home Address _______________________________________ Telephone ____________________________

City and State _______________________________________________________________________________

Work Name and Address ______________________________________________________________________

If I can not be reached at either number above, please call ____________________________________________

(Name)

Relationship ____________________________________ Telephone ________________________________

In Town Physician _______________________________ Telephone ________________________________

Dentist _________________________________________ Telephone _______________________________

Out of Town-if parents(s) are not present on out-of-town trips, In case of injury or sickness to:

__________________________________________________________________________________________

(Child’s Name)

This form gives permission to a qualified Physician or Dentist for emergency room services to give my child medical attention as needed. Parents(s) signature herein gives proof of permission to treat my child.

Parent(s) Signature _________________________________________________________________________

All Medical forms are due at time of registration for Gala Day session.

No Exceptions!