Parental Contact Permission And Medical Consent Form printable pdf download

PARENTAL CONTACT, PERMISSION AND MEDICAL CONSENT

Student’s Name: _______________________________________ Date of Birth_________________

Address: ________________________________________________________________________

School:____________________________ Grade (2014-2015)______ Home Phone_____________

Student Email Address: _____________________________________ Student Cell______________

Who invited your student to Road Trip?_________________________________

The undersigned(s), being the lawful parent(s) and/or guardian(s) of the above child, hereby consents to the participation

by the child in Road Trip Events, including bus transportation to and from activities conducted by Middle School Ministries,

and to the participation of the child in all events relating to the activities on June 26 – August 31, 2014. The above child

will be participating in the following activities (please check appropriate boxes):



Pool Party (Wednesday, June 26) $0



Sky Zone (Wednesday, July 2) $25



Pool Party (Wednesday, July 16) $0



Black Rock (Wednesday, July 23) $25



Tubing (Wednesday, July 30) $30



Paint War (Wednesday, August 6) $10



Movie Night (Wednesday, August 13) $10



Hershey Park (Wednesday, August 20) $50



BBQ and Bonfire (Wednesday, August 27) $10



Overtime and Ozzy’s (Wednesday, August 31) $10

Please note: Some activities include swimming and/or waterpark.

The undersigned hereby further authorize(s) any of the staff, employees, agents and representatives of Organizer

to provide for, approve and authorize any health care at any hospital, emergency room, doctor’s office or other

institution; employ any physicians, dentists, nurses, or other person whose services may be needed for such

health care; review and, if necessary, disclose the contents of any medical records; execute any consent form

required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care

to the child. Health care shall include, but not be limited to, the administration of anesthesia, X-ray examination,

performance of operations, diagnostic and other procedures.

If there is no medical emergency, the Organizer will first use reasonable efforts to contact the parent(s) and/or

guardian(s) before administering or authorizing any treatment.

Notwithstanding other provisions in this Consent Form, Organizer shall not have the authority to withhold or

withdraw life-sustaining procedures for the Child.

This Consent Form may be revoked at any time before the expiration date with written notice to Organizer.

Name of Parent (please print): ________________________________________________________

Signature of Parent/Guardian: ________________________________________________________

Parent Email: _______________________________ Parent Contact Number: __________________

Alternate Contact Name & Number: ____________________________________________________

Health Insurance Name & Policy Number: _______________________________________________

Parental Contact Permission And Medical Consent Form

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