Children'S Activity Consent Form printable pdf download

’

HILDREN

CTIVITY

ONSENT

ORM

Name of child __________________________________________________________________

Name of parent(s) or guardian(s) ___________________________________________________

Address _______________________________________________________________________

Home telephone______________________ Work telephone ____________________________

Other person and/or number to call in emergency ______________________________________

Medical Information

Is your child presently being treated for an injury or sickness or taking any medication?

Yes________ No________

If yes, please explain. ____________________________________________________________

______________________________________________________________________________

Does your child have a physical handicap or illness that would prevent him or her from

participating in normal rigorous activity? Yes______ No______ If yes, please explain.________

______________________________________________________________________________

Consent and Certification

______________________________________________________________________________

I, the undersigned, being the parent or legal guardian of the child named above, do hereby

consent to the participation of my child in the following activity conducted by _______________

_________ Church:______________________________________________________________

______________________________________________________________________________

I certify that my child is physically fit and adequately prepared to participate in this event.

Medical Treatment Authorization

I understand that I will be notified in the case of a medical emergency. However, in the event

that I cannot be reached, I authorize the calling of a doctor and the providing of necessary

medical services in the event that my child is injured or becomes ill. I authorize one or more of

the following persons to make emergency medical care decisions on behalf of my child, if

required by law or a health care provider: ____________________________________________

______________________________________________________________________________,

or another adult chaperone designated by the pastor. I authorize these persons to act in my place

to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical

diagnosis or treatment, and hospital care.

I understand that ____________ Church will not be responsible for medical expenses incurred solely

on the basis of this authorization. I also understand that the designated adult chaperones reserve

the right to restrict my child from any activity that they do not feel is within the physical

capabilities of my child.

___________________________________________________ _________________________

Signature of Parent or Guardian

Date

Children'S Activity Consent Form