Parental Consent Form

From the Open Files of: Eastern Minnesota Resource Center Contributed by: Prince of Peace, Burnsville, MN This file is available in Rich Text Format version for editing

Prince of Peace Parental Consent Form   Youth Name ___________________________ Birth Date _______________________   Address _______________________________ City _____________________ Zip ____   Mother's Name _____________________________   Father's Name ______________________________   The undersigned does hereby give permission for our (my) child, _____________ to attend and participate in activities sponsored by (your church name). 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 advice 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. The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities. Home phone ___________________________ Work phone _______________________ Other phone numbers _________________________ Phone _______________________ Other emergency contact _________________________ Phone ____________________ Family Doctor __________________________ Phone ___________________________ Insurance Company ______________________________________________________ Insurance policy or Group # ________________________________________________ List special medical conditions, allergies and other medical information. Include date of last tetanus shot, other inoculations, medications, major illnesses, etc.     Parent's Signature _______________________________________________________

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