Choose the Event Sponsor
Authorization of the staff of the Heights International Ministries, South Canonsburg Church, Evangelization Society and/or the Church at the Heights and consent for emergency medical treatment for the designated individual listed below.
Name of the Insured (Child or Dependent) *
Name of the Insured (Child or Dependent)
Address
Address
Name of the Parent/Guardian Granting Authorization/Consent
Name of the Parent/Guardian Granting Authorization/Consent
Phone
Phone
Starting Date of Event
Starting Date of Event
Ending Date of Event
Ending Date of Event
Name of Insurance Company
Insurance Policy Number
Group Number
Name of the Person Holding the Insurance Policy
You MUST check this box to confirm signature and verify consent *