Event Name *
Check All that Apply
Student's Name *
Student's Name
Student's Birthdate *
Student's Birthdate
Parent/Guardian Name *
Parent/Guardian Name
Address *
Address
Phone No. *
Phone No.
Emergency Contact *
Emergency Contact
Emergency Contact Phone No. *
Emergency Contact Phone No.
I am the parent and legal guardian of the child listed above. I hereby authorize the Student Minister, Brian Dillon, and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this (CHURCH) into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my child. The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further authorize the Student Minister, Brian Dillon, and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this (CHURCH) to receive physical custody of my child, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the Student Minister, Brian Dillon, and his/her officers, agents, servants, or employees that are 18 years of age or older who supervise the activities at this (CHURCH). It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable. If you agree, sign your name below:
Today's Date *
Today's Date