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 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 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 .