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CUMC Medical Consent 2010-2011

This document is a medical consent form for a youth attending Christ United Methodist Church youth activities from 2010-2011. It provides the youth's name, address, contact information, emergency contacts, insurance information, and consent from the parent or legal guardian for medical treatment. The parent agrees to pay costs associated with any necessary medical services and transportation costs to return the youth home if needed. The parent also provides consent for the youth to ride in vehicles designated by supervising adults for church activities.

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Matthew Dunn-Rankin
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55 views

CUMC Medical Consent 2010-2011

This document is a medical consent form for a youth attending Christ United Methodist Church youth activities from 2010-2011. It provides the youth's name, address, contact information, emergency contacts, insurance information, and consent from the parent or legal guardian for medical treatment. The parent agrees to pay costs associated with any necessary medical services and transportation costs to return the youth home if needed. The parent also provides consent for the youth to ride in vehicles designated by supervising adults for church activities.

Uploaded by

Matthew Dunn-Rankin
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Christ United Methodist Church Youth

Medical Consent Form – 2010-2011

Youth’s name: __________________________________ Age: ____ Birth Date: __________

Address: ____________________________________________ Phone: _________________

City: _______________________________________ State: ______ Zip Code: ___________

School ________________________________________ Grade (as of fall, 2010): _________

Parent (s) business phones: _______________________ _________________________

E-Mail Address: ________________________ Parent’s E-Mail: _______________________

To Whom It May Concern:


I (We), the undersigned do hereby give permission for my (our) child, ____________________
to attend and participate in activities sponsored by the Christ United Methodist Church Youth
Group from now until December 31, 2011. I (We) understand that youth activities, such as
sports, field trips and other activities, carry with them a certain degree of risk.
I (We) 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 of any physician or dentist
licensed under the provision 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 my (our) 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 my (our) child to ride in any vehicle
designated by the adult in whose care the minor has been entrusted while attending and
participating in activities sponsored by Christ United Methodist Church.

Medical Insurance Company: Emergency phone numbers:

______________________________________ _________________________________
Policy number:
______________________________________ __________________________________

SIGNATURE(S):

Father / Mother _____________________________________________________ date ______________

Legal Guardian: _____________________________________________________ date ______________

Below, please list any allergies or special medical problems your child may have. Thank you.

NOTARY
Before me this day __________________________(date), _______________________________(parent)

Personally known to me or who has produced _______________________________________ (driv. Lic. #)


As identification and who executed the forgoing instrument for the purpose therein expressed.

Notary Signature: _______________________________________ My commission expires:

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