Parental Consent & Emergency Medical Release Form
Child’s Name: __________________________ Birth Date: _________________
Address: ______________________________ City: ___________ ZIP: ______
(I) (We), the undersigned parent(s) of __________________, a minor, do hereby consent
to said Minor participating in youth ministry events conducted by First Baptist Church.
Authorization of Consent to Treatment of Minor:
(I) (We), the undersigned parent(s) of __________________, a minor, do hereby
authorize First Baptist Church hereinafter “Agent”, for and on behalf of the undersigned
to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment,
and hospital care which is deemed advisable by, and is to be rendered under the
general or specific supervision of any physician and surgeon licensed under the provision
of the Medical Practice Act, whether such diagnosis or treatment is rendered at the
office of said physician or at a hospital, during all times that the Minor is in the presence of
said Agent.
It is understood that the authorization is given in advance of any specific diagnosis, treatment,
or hospital care being required, but is given to provide authority and power on the part of
our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or
hospital care which the aforementioned physician in the exercise of his best judgment
may deem advisable and release Agent from all damages of same.
The undersigned does also hereby give permission for _____________________, a minor,
to ride in any vehicle designated by the Agent in whose care the minor has been
entrusted while attending and participating in said activity.
This authorization shall remain effective through the 31st day of August, 2008, unless sooner
terminated in writing.
Parent/ Guardian _____________________________________ Date ___________
Parent/ Guardian _____________________________________ Date ___________
Home Phone: _________________________ Cell Phone: _____________________
Other emergency contact: ________________________ Phone: _______________
Family Doctor: ____________________________ Phone: ____________________
Insurance Company: ____________________________________________________
Insurance Policy or Group #: ______________________________________________