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Summer Events - Consent Form

This document contains a parental consent form for a child to participate in activities at the Korean United Methodist Church of GW Youth Group. It provides permission for medical treatment and transportation if needed. It collects basic contact and medical information including insurance details, allergies, medications, and emergency contacts. Parents must sign agreeing to terms and providing their information and the child's medical details on the reverse side.

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Keon Gunie Huh
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49 views

Summer Events - Consent Form

This document contains a parental consent form for a child to participate in activities at the Korean United Methodist Church of GW Youth Group. It provides permission for medical treatment and transportation if needed. It collects basic contact and medical information including insurance details, allergies, medications, and emergency contacts. Parents must sign agreeing to terms and providing their information and the child's medical details on the reverse side.

Uploaded by

Keon Gunie Huh
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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Korean United Methodist Church of GW

- Youth Group Department –


(PARENTAL CONSENT FORM)

Name ____________________________________ Age __________ Birth-date ________________


Address ________________________________________________ Phone ____________________
City _________________________________ State ______________ Zip Code ________________
School ________________________________________ Grade (rising) ______________________
Parent(s) business or Emergency phone # ________________________________________________

To whom it may concern:


The undersigned does hereby give permission for our (my) child, ____________________________,
to attend and participate in
_________________________________________________________________. 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 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) child to return to pay all costs and expenses in mentioned
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 sponsored by KUMC of GW.

Hospital Insurance Yes ___ No ___ Father ___________________________


Insurance Company _______________ Mother __________________________
Policy Number ___________________ Legal Guardian Signature ___________
Emergency Phone Number ___________ Parent(s) Phone #s _________________

Name of Parent/Guardian of the Applicant Phone #

Signature Date

* On the reverse side of this page, please list any allergies or special medical concerns
your child may have. Thank you.
MEDICAL INFORMATION
Is your son/daughter currently under the care of a physician for a medical problem? Yes ____ No _____
If yes, please explain....

_________________________________________________________________________

_________________________________________________________________________

Is your son/daughter currently taking medication prescribed by a physician? Yes _____ No ______
If yes, please list each medication and circle whether or not it needs refrigeration.
___________________________________________________________ Requires Refrigeration

___________________________________________________________ Requires Refrigeration

Please list any over-the-counter medications you do not wish dispensed to your child for treatment for minor
ailments or injuries.
________________________________________________________________________________________

________________________________________________________________________________________

Does your son/daughter have any of the following medical conditions?


If yes, please explain any details under the condition:
Chronic health problems? Yes ______ No ______
________________________________________________________________________________________

________________________________________________________________________________________

Allergies (e.g. food, bee stings, medications)? Yes ______ No ______


________________________________________________________________________________________

________________________________________________________________________________________

Program limitations? Yes ______ No ______

________________________________________________________________________________________

________________________________________________________________________________________

Is there any other information about your son/daughter that an attending physician needs to be aware of?
If yes, please explain...
________________________________________________________________________________________

________________________________________________________________________________________

Date of Last Tetanus / /


Date of Last MMR / /

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