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PARENT CONSENT TO TREAT A MINOR FORM

Being the parent or legal guardian of _____________________________ (minor’s printed name), I ______________________________ (parent/guardian’s printed name) do consent to any x-ray, anesthetic, medical, surgical, or dental diagnosis or treatment that may be deemed necessary for my minor child. Further, I understand that all efforts will be made to contact me prior to treatment. In the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor child. I further understand that the doctors, dentists, and other providers attending to my child will take all reasonable safety precautions during their care.

Further, as parent or legal guardian, I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the dental, medical, or hospital care or treatment that is given to my child. Any policy of the church or organization sponsoring this event will be used as the secondary coverage.

Minor’s date of birth: ___________________________________
Parent/Guardian Signature: ___________________________________ Date: ______________

 

PARENT OR GUARDIAN OF A MINOR CONSENT AND HOLD HARMLESS FORM

Name of activity:_____________________________ Date:_____________________________
Child’s Name:_____________________________
Date of birth:_____________________________ Age:_____________________________ Sex:_____________________________ Address:_____________________________
Phone number:_____________________________

I, _______________________ (printed name of parent/guardian) being the parent or legal guardian of ____________________________ (printed name of minor) have been informed of the above activity sponsored by _________________________________ (name of church or organization) and hereby give my consent for my minor child to participate in this activity.

I understand that all reasonable safety precautions will be taken by the leaders of this activity, and that the possibility of an unforeseen hazard does exist. I further agree not to hold ____________________________________ (name of church or organization) its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the minor listed on this form.

I also understand that my minor child is to be excluded from the following activities:

Signature of parent/guardian:_____________________________ Date:_____________________________