PARENTAL CONSENT FORM

 

 

 

To whom it may concern:

 

The undersigned does hereby give permission for our (my) child,                                                   

(Name of Child)

 

                                , to attend and participate in activities sponsored by                                                                                                                                                           (Name of Organization)

 

on                          .

(Date)

 

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advise of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

 

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.

 

Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

 

 

 

Emergency phone numbers

 

                                                                      

                                                                      

                                                                    

                                                                      Participant Date

 

                                                                    

Father     Date

 

                                                                    

Mother    Date

 

                                                                     

Legal Guardian               Date

 

Please list any allergies or special medical problems your child may have.  Thank you.