Parental Consent & Medical Release Form

Pleasant Valley SDA Church

High School Ministry

Name of Child: ______________________

Name of Parent(s) / Guardian(s): _____________________________________

Home Phone: (___)_____ _______ Work Phone: (___)_____ _______ Cell Phone: (___)_____ _______

Address: _________________________________

_________________________________________

I, ________________________ give permission for my child, _____________________ to attend and participate in ALL ACTIVITIES sponsored by the Pleasant Valley Seventh-day Adventist Church from the dates of ________________ through ______________.

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the Pleasant Valley SDA Church.

SIGNED: ______________________________ DATE: __________________________

q Yes - Hospital Insurance

q No – Hospital Insurance

Insurance Company: ______________________________

Policy Number: __________________________________

Tetanus Immunization Status (within 5 years)

q Yes

q No

Allergies:

Medications:

Food:

Medications to be taken:

Name Dose How Often

________________________ ____________________________ _____________________________

________________________ ____________________________ _____________________________