CCPV - Medical Consent Form

Medical Authorization & Consent

This form is required for all participating persons 13-18 years old and must be completed by the individual's parent or legal guardian.
The undersigned parent or legal guardian grants permission for the church's designated leaders and volunteers to obtain emergency medical treatment for the participant if deemed necessary while participating in church-sponsored trip.

Child Information:

First Name

Last Name

Birthdate

Gender

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Allergies

If including health insurance/doctor info, please list off health insurance company name and child's insurance ID (optional).

Notes or special accommodations?

NA

Yes

Please list any additional notes or accommodations here:

Parent or Guardian Information:

First Name

Last Name

Phone Number

Email

By selecting "I Agree", I certify that I am the parent or legal guardian of the participant, have carefully reviewed this Medical Consent Form, and authorize the medical treatment and permissions described herein.

I agree

Signature

Medical Authorization & Consent

Address

Service Times

Contact Info

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