Authorization Card 2025 - 2026

Medical and emergency info permission slip for Children and Student Ministries. (In the "Name" field, please enter the child's name to which this form applies)

Your name *

Email address *

Birthday *

Phone Number *

Address *

Grade *

School

Name(s) of Parent(s)/Guardian(s) *

Health Insurance (Company, Name of Insured, Policy #) *

Name and Phone# of Doctor

Medical Note

Please read the following. By entering the date below and submitting this form, you are agreeing to the text below. *

As parent/guardian of the child named above, I hereby give permission for my youth to participate in the activities of Pathway Church. I entrust my child into the care of the adult staff during such participation. I hereby authorize the adult staff to consent to any x-ray exam, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of, any physician and surgeon licensed under the provision of the California Medical Practice Act or of the laws of the State or Country in which the medical care is being sought and on the medical staff of any hospital; or to consent to any x-ray exam, anesthetic, dental or surgical diagnosis or treatment to be rendered to my youth by any dentist licensed under the California Dental Practice Act or the laws of the State or Country in which the dental care is being sought. It is understood that this authorization is given in advance of any x-ray exam, anesthetic, medical, or surgical diagnosis or treatment and hospital care being required but is given to provide authority and power on the part of the adllt staff to give specific consent to any such examination, anesthetic, diagnosis, treatment or hospital care which the aforementioned surgeon, physician and/or dentist, in the exercise of his/her best judgment may deem advisable. I also authorize any hospital which has provided treatment to my child to surrender physical custody of the child to the Adult Staff upon the completion of treatment. I also agree to fully pay all costs of medical or dental care incurred for my child by the Adult Staff under the authorization. I also understand that this consent is valid January 1, 2025 through January 1, 2026.

Media Consent

I grant permission to Pathway Church and to the mass media to photograph, record, or videotape my child during the course of his/her involvement and grant permission for the use of such reproductions for publicity, fundraising or my public relations use.

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