Parental Consent/Medical Release

Parental Consent/Medical Release Form

I, _________________________________, do hereby give my permission for my

child, _______________________________, to participate in the activities that are sponsored by Tolar Baptist Church in the year of 2010.

I authorize an adult, in whom I have entrusted the care of my minor, to consent to any examination, x-ray, anesthetic, surgical, medical, or dental diagnosis or treatment, hospital care that is necessary to be rendered to my child under the supervision of advice of a licensed physician or dentist.

I will pay the cost any expenses that result of my child’s injury or illness. Should it be necessary that my child return home, whether due to illness, injury, or conduct, I will assume all transportation costs. I also give my permission for my child to ride in any vehicle determined by the adult in whose care I have entrusted my child while attending activities sponsored by Tolar Baptist Church.

Parental/Guardian Signature _________________________________Date____________

Participant’s Signature____________________________________Date_____________

Name of Participant________________________________Age____ D.O.B.__________

Address_______________________________________________Phone_____________

SS#______________________________________

Parent’s Work Number______________________________

Emergency Number________________________________

Emergency Name and relation to child________________________________________

Insurance Company___________________________________Policy#______________

List any allergies or medical problems that your child may have

_______________________________________________________________________