CONSENT FOR MEDICAL TREATMENT FORM
I give my child (print full name) __________________________ my permission to ride in vehicles provided for youth related activities, and release RESURRECTION LUTHERAN CHURCH and its ADULT ADVISORS, CHAPERONES, AND DRIVERS from any damages that may result due to accident and/or injury.
Parent / Guardian Signature __________________________________
I, the undersigned, hereby authorize a representative of RESURRECTION LUTHERAN CHURCH to consent to and authorize emergency medical treatment, surgery or dental care to be given to my son/daughter (print full name and SS#)
________________________________________________________________________ as considered advisable or necessary in the judgment of an emergency medical professional or attending physician.
Parent / Guardian Signature __________________________________
Parent / Guardian __________________________
Address _________________________________
________________________________________
Mother's phone:
Home
____________________
Work
____________________
Cellular
___________________
Father's phone:
Home
____________________
Work
____________________
Cellular
___________________
Another person to contact in an emergency:
Name
______________________
Phone
______________________
Relationship
_________________
Family Physician
______________________________________
Physician Phone ________________
Family Insurance
Company
______________________________
Policy Number
__________________
Allergies ___________________________________________________
Medical Allergies _____________________________________________
Physical Limitations ____________________________________________
Preexisting Conditions (physical, emotional, etc.) ______________________ ___________________________________________________________
Other comments or information related to health _______________________ ___________________________________________________________
Current Medication -- on other sheet.
(revised 11/00)