Authorization for Participation and Consent to Medical Treatment of a Minor
Name of Youth:
Street:
City:
Phone:
PERMISSION TO PARTICIPATE IN YOUTH ACTIVITIES:
(Youth’s name:)
has me permission to participate in Youth Activities sponsored by Christ
Lutheran Church, except for those activities listed as restriction. I agree that
Christ Lutheran Church will not be help responsible for accidents arising
thereof. I am responsible for any medical obligations incurred during these
activities and give the sponsors permission to seek medical treatment of my
child in case of injury or illness. I also give permission for the use of
photographs including my child in any publicity, I understand my child may
travel to and from events in rented cans or private cars and do no hold the
youth sponsors responsible for accidents arising thereof.
MEDICAL INFORMATION:
Allergies:
Activities to be Restricted:
Emotional or Physical Concerns:
MEDICATION REQUIRED ON A REGULAR BASIS-LIST ALL::
Medication:
Dosage:
Time Given:
Medication:
Dosage:
Time Given:
Permission for youth sponsor(s) to supervise child while taking the above
medication. YES or NO
Permission for youth sponsor(s) to administer pain reliever (Tylenol or Advil)
if needed. YES or NO
(Over for Emergency Contact People)
Subscribed and sworn to before me, by the said (Parent/Guardian)
, this the
day of
, 20 , to certify which,
witness my hand and seal of office.
My Commission Expires:
Notary Public in and for the STATE OF TEXAS
County of
EMERGENCY CONTACT PEOPLE:
NAME:
PHONE: (H)
RELATIONSHIP:
(W)
NAME:
PHONE: (H)
RELATIONSHIP:
(W)
DOCTOR:
PHONE:
DENTIST:
PHONE:
INSURANCE COMPANY:
POLICY #:
NAME OF POLICY HOLDER:
PHONE: