Insurance Information for teen Participant in Good Shepherd Cumming trips and activities

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Please fill this form in completely so that, in case of emergency during one of our events, we can assist your teen as needed.

I am covered by a hospitalization and medical insurance under policy. If you are not covered, then type N/A on all other answers. You're signature will attest to you taking financial responsibility should any medical treatment be necessary. *

Yes

Policy # and Issuer (if not covered type: N/A) *

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact relationship to child *

By typing your name below you are giving your permission for the Good Shepherd staff to treat or seek treatment of your child in case of emergency. *

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