Medical Consent Form printable pdf download

Medical Consent Form

and

Approval by Parents or Legal Guardian

Name of youth participant_________________________________________________________

Birth date (month/day/year) ____/____/______

Address (need street address if you have a P.O. box)

_________________________________________________________

City__________________________________________________________________________

State _____ Zip _________

Youth Cell Phone#____________________ Youth E-mail Address________________________

Special considerations or

restrictions:____________________________________________________________________

In case of emergency involving my child, I understand every effort will be made to contact me. In

the event I cannot be reached, I hereby give my permission to the medical provider selected by

the adult leader in charge to secure proper treatment, including hospitalization, anesthesia,

surgery, or injections of medication for my child. Medical providers are authorized to disclose to

the adult in charge examination findings, test results, and treatment provided for purposes of

medical evaluation of the participant, follow-up and communication with the participant’s parents

or guardian, and/or determination of the participant’s ability to continue in the program activities.

Participant’s signature __________________________________________ Date ____________

Parent/guardian printed name

_____________________________________________________________________________

Parent/guardian signature

_____________________________________________________________Date ____________

Parent/Guardian Phone numbers/e-mail

_____________________________________________________________________________

(Area code and telephone number (best contact and emergency contact) E-mail (for use in sharing more details about the

trip or activity)

Medical Consent Form