Parent Permission

Parent Permission & Medical Release Form

If you wish to consent to medical treatment for your child, please complete and sign the following form. This form will be used only in the unlikely event that we cannot reach you in time when your child needs immediate emergency medical treatment. We pray that we will never need to use this form , but we offer it as a safeguard for your child.

Consent to Medical Treatment

Child's Name

My above named child has permission to with the authorized personnel/supervisor of Rockaway Assembly of God church for special events/activities.

Name of Parent of Legal Guardian

Home Address

Telephone

Secondary Number

Child's Birthdate

I, the undersigned parent or legal guardian of the above named child do hereby grant my permission and consent to for said child to receive emergency medical care if (1) such care is deemed necessary by the adult supervisor having custody of my child at Rockaway Assembly of God , 113 East Main Street Rockaway, NJ or while participating in any activity away from church grounds, (2) the proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my personal consent would reasonably jeopardize the life, health, or well-being of the child effected; and (3) I cannot be personally contacted.

I further acknowledge that I have read and understand the above statements.

Parent's Name *This constitutes and electronic signature

Date

Name of Insurance

If you do not have insurance please initial below that any expenses occured will be your responsibility.

Policy Number

Name/Phone Number of Physician

Is your child taking any medicine? If none please write, "none."

Does your child have any allergies? If none please write, "none."

Any other comments or medical information? If none please write, "none."

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