Church Consent Form printable pdf download

Church Consent Form

MEDICAL EMERGENCY SERVICES ALLOWANCE RELEASE

In the event that my minor child, _________________________________________, has need of medical

attention, I do hereby give my permission for the staff and sponsors of the __________________ Church

to seek such help including emergency surgery if the particular medical emergency warrants. I understand

that every effort will be made to contact me or my alternate responsible party prior to emergency surgical

procedures, unless the particular situation does not allow due to the threat of loss of life.

I give my minor child full consent to attend the activities of __________ Church from _________________

to ____________________. It is my understanding that the staff and volunteers of __________ Church

will take all of the necessary precautions to ensure the safety of my child. I do hereby release the above

stated organization from any legal or financial obligation due to the injury of my above named minor.

Minor’s name: _______________________________________________________________

Address:_____________________________________________________________ ___________

Parent/legal guardian name: _________________________________________________________

Telephone numbers where you can be reached during this time:

Alternate person to contact in case of emergency if parent can’t be reached:

Name, relationship

Phone

Name, relationship

Phone

INSURANCE INFORMATION

[PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR CHILD’S INSURANCE CARD]

MEDICAL HISTORY/KNOWN ALLERGIES TO FOOD, DRUGS, BEE STINGS, ETC.

______________________________________________________________________________________

(If more space is needed please use back of sheet)

LIST ALL MEDICINE CURRENTLY TAKING AND WHAT MEDICAL CONDITION IT IS TAKEN FOR:

____________________________________________________________________

_______________________________________________________________________

TRANSPORTATION ALLOWANCE

My above listed child is allowed to travel with Lake Hills Church in the transportation provided by the above

named church.

I AGREE TO THE TERMS AND CONDITIONS STATED ABOVE.

____________________________________________________________________________________

Signature of Parent/Guardian

Date

Church Consent Form