Medical Authorization Form

Consent form for parental consent for medical authorization.

Child/Youth First Name

Child/Youth Last Name

Child/Youth Grade

Child/Youth Age

Address

City

State

Zip Code

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number

Parent/Guardian Email Address

PARENTAL CONSENT I understand that my child/youth will be participating in a number of activities for the calendar year 2023, which carry with them a certain degree of risk. Some of the activities are swimming, boating, hiking, camping, field trips, sports and other activities which the church may offer. I consent for my child to participate in these activities.

Yes, I consent.

No, I do not consent.

PARENTAL CONSENT I understand that my child/youth may travel offsite during the course of the year, whether by walking, chauffeured or staff transportation. I give my consent for my child/youth to participate.

Yes, I consent.

No, I do not consent.

PARENTAL CONSENT Please indicate any restrictions on your child’s/youth's activities:

I represent that my child/youth is physically fit and has the necessary skills to safely participate in these activities.

I represent that my child/youth has restrictions on the following particular activities.

I also understand and give consent for my child to travel to and from these events in transportation provided by volunteer drivers.

MEDICAL TREATMENT AUTHORIZATION It is my understanding that the Church will attempt to notify me in care of a medical emergency involving my child/youth. If the church cannot reach me, then I authorize the church to hire a doctor or health-care professional, and I give my permission to the doctor or other health-care professional, to provide the medical services he or she may deem necessary. I will pay for any medical expenses so incurred.

Yes, I consent.

No, I do not consent.

MEDICAL TREATMENT AUTHORIZATION I will notify the church if I feel there are any health considerations that would prevent my child/youth’s participation in any of the activities listed above.

Yes, I consent.

No, I do not consent.

Please list any allergies or other health considerations here:

Insurance Company Name

Policy/Group Number

Today's Date

Parent/Guardian Signature