Medical
Consent Form
I,________________________ , give my
permission for _____________________
to participate in any activities including but not limitted to lake & pool
swimming, boating
& travel to and from any Cross Mountain Church sponsored events. I understand that if my
child is in need of medical assistance, the adult sponsors will make every effort
to see that my
child's needs are attended to. I also understand that every
effort will be made to contact me
before my child receives any treatment.
I can be reached at home phone__________________
work phone____________________ cell phone__________________
If I cannot be reached, another person to contact in the event of an emergency
is__________________________ and their phone number
is_______________.
Below is
medical information that may be helpful while treating your child.
Insurance Company ___________________________________________
Group Policy# ________________________________________________
Name of Primary Card Holder_________________________________________
Secondary Insurance Company Policy# ________________________________
Insured's Relationship to child ________________________________________
Medical History:
List any medications youth is currently taking. Please include over-the-counter
medications. List any known allergies:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Has the youth been seen by a doctor for any reason in the last three
months?
Yes____ No____
If yes, please explain:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Is the child current on all immunizations and shots?
_______________________
If not, what is not current?
_________________________________________________________________
Other pertinent information about your child:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Signature of parent or guardian
______________________________________date
____________
