Church Transportation Consent Form
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1
2CHURCH TRANSPORTATION CONSENT FORM
Dependent Name
Health History
Please list any Special Medical Conditions
Relationship
Address
City State Zip
Home Phone
Date of Birth
Social Security #
Last Tetanus Shot__________________________
Parent / Guardian
Medications to be taken (list with directions)
Work Phone
Address
City, State, Zip
Home Phone
Medication Allergies? List if any
_________________________________________
Doctor’s Name
_________________________________________
Office Phone
May be given as necessary:
Emergency Contact –
if parent/guardian cannot be reached
Emergency
Aspirin
Yes_____ No_____
contact Home
Tylenol
Yes_____ No_____
Phone Address
Ibuprofen
Yes_____ No_____
City, State, Zip
Work Phone
Any Specific Activities
Hospital Preference
Encouraged _________________________
Insurance Info –
Attach copy of front and back of card
Insurance Company
Discouraged_________________________
Group Number
I hereby give consent in advance to the designated Youth Leaders
Group Name
of _______________________ Church and to the physicians or
Insured’s Social Security #
hospitals selected by them to render first aid treatment or deny
treatment as in their judgment is reasonably necessary, including,
THIS FORM MUST BE NOTARIZED IN ORDER FOR
but not limited to, hospitalization, diagnosis including taking
YOUR YOUTH TO TRAVEL AND PARTICIPATE IN
specimens, and x -rays, giving blood transfusions, and medications,
THE ______________________ CHURCH YOUTH
anesthesia, and surgery for my dependent listed above. I
understand that the Youth Leaders of _________ will attempt to
MINISTRIES. THANK YOU!
contact me before securing medical treatment, but that this consent
is given in case I am not available in an emergency.
__________________________________________________
I release all Youth leaders and staff affiliated with _________ from
Signature of parent/guardian in presence of Notary Public
Date
any and all claims, loss, cost, damage, or expense arising out of or
from any accident or other occurrences causing injury to any
person or property.
_______________________________________________________
Signature of Notary Public
Date
Notary Seal
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