This health history is correct as far as I know. The person herein described has my permission to engage in all prescribed
activities except as noted above. The following authorization empowers the staff of FIAC, Inc., Youth Group to take whatever
steps they deem necessary to insure the wellbeing of your child should a medical emergency occur during a youth group
meeting/activity. Every attempt will be made to contact the parent or emergency contact provided.
I do hereby authorize FIAC, Inc. Youth Group to take necessary emergency measures in the treatment of my son/daughter if needed. My son/daughter is in good
physical health and does not have any disabilities which may be aggravated except as noted on this form. I release FIAC, Inc.,
and its agents from all responsibilities other than supervised, scheduled activities. In the event that I cannot be reached in an
emergency, ] hereby the authorize the physician selected by FIAC, Inc. to hospitalize, secure proper treatment for, and order
injections; anesthesia and surgery for my child named above
