Medical Consent Waiver (Page 2 of 2) in pdf

Medical Consent Waiver Page 2

Phone No. of Insurance Company (

)

Policy No. of Insurance Policy

Name of Policy Holder

Other comments or suggestions from the parent or guardian concerning this child

I understand that, in the event my child requires medical or dental treatment while engaged in the Activity,

reasonable efforts will be made to contact me; however, if I cannot be reached, I authorize an adult, in whose care

the minor has been entrusted, to consent to any X-ray examination, injections, anesthetic, medical, surgical or dental

diagnosis and treatment, and hospital care and treatment advised and supervised by a physician, surgeon or dentist

(as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an

outpatient or in any hospital. To the best of my knowledge, I have listed above all of my child’s medical allergies,

medications being taken, medical problems and other pertinent information. My child has permission to participate

in all prescribed activities except as noted by me. Should it be necessary for our (my) child to return home due to

medical reasons or otherwise, the undersigned shall assume all transportation costs.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical

and dental services rendered to the aforementioned child pursuant to this authorization.

The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult

in whose care the minor has been entrusted while attending and participating in activities sponsored by FIRST

ALLIANCE CHURCH.

Signature

Date

(Parent or Guardian)

Print Full Name

Date

Medical Consent Waiver Page 2