Church Parent Consent Form For Group Activity And Medical Authorization
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1_____________________ CHURCH
Parent Consent Form for Group Activity and Medical Authorization
has my permission to participate in
at
on
Bring:
Method of Transportation:
Lunch
Private Car
No Lunch (It’s provided)
Church Van
Other
Other
Additional Information:
Please fill in the information below:
Child’s Social Security #:
Do you have Health Insurance? Yes No If yes, Policy
Name of Health Insurance Co.:
Health Information:
Has your child had any of the following? (Check if answer is YES)
Frequent or severe headaches
Asthma
Ear, nose or throat trouble
Heart trouble
Dizziness or fainting spells
Frequent colds
Shortness of breath
Diabetes
List Allergies and/or Allergic Reactions:
List any medication you child now takes:
Should it be necessary for my child to have medical treatment while participating in this
activity, I hereby give the person(s) in charge permission to act on my behalf to SECURE
HOSPITALIZATION or medical services deemed necessary and appropriate by the
physician. I absolve said Church from any and all forms of negligence and wrong treatment
incurred in the procurement and process of hospitalization and medical treatment. I
understand that _____________________ Church has no accident insurance. Any cost
incurred shall by my sole responsibility.
Signature
Relationship to Participant
Home phone
Work Phone
Address
City
-------------------------------------------------------------------------------------------------------------
Tear Off and Keep for Your Information
This activity is organized by
of
(Adult in Charge)
Church.
Departure from church:
a.m./p.m.
Return to home:
____ a.m./p.m.
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