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Coburn United Methodist Church
Youth Emergency Medical Authorization
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Youth's Name ___________________ _______________ ______
Last
First
MI
Age ____ Date of Birth ____/____/_______
Social Security ______-___-_______ Home Phone (____) ____-________
Residence ______________________________________________ (NO PO Box)
_________________________ ____________ ______-_______
City
State
Zip
Home Church _________________________________
Check box if Phone or Residence is new
Custodial Parent: Father
Mother
Mother's Name __________________________________________
Work Phone (____) ____-________ Employer
____________________________________
Father's Name ___________________________________________
Work Phone (____) ____-________ Employer
____________________________________
List two neighbors or nearby relatives if you cannot be contacted.
Name __________________________________________________
Address________________________________ Phone (____) ____-________
Name __________________________________________________
Address________________________________ Phone (____) ____-________
Person(s) with whom child is NOT to be released:
_________________________________
___________________________________________________________________________
This form will be kept on file at the church office:
3618 Maple Ave., Zanesville, Ohio
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