Free Parental Permission Medical Consent & Liability Release

Parental Permission Medical Consent and Liability Release

CHILD’S NAME: ____________________________
AGE: _____________________________________
BIRTH DATE _______________________________
ADDRESS__________________________________
__________________________________________
SOCIAL SECURITY# ___________________________
SCHOOL ___________________________________
GRADE ____________________________________

PARENT(S)/GUARDIAN NAME(S)
__________________________________________
___________________________________________
PHONE(S)___________________________________
___________________________________________
TO WHOM IT MAY CONCERN:
I/We, of _____________________________________________________ the parent(s) or legal guardian(s) of the Participant do/does hereby give permission for the following child: _____________________________________________________ ____________________________________ (“Participant”), to attend and participate in sports, events, and retreats (“Events”) held by _____________________________________ (“Organizer”) during ____________________________ to _____________________________.
LIABILITY RELEASE
In consideration of Organizer allowing the Participant to participate in the Events, I/we do hereby release, forever discharge and agree to hold harmless Organizer, its directors, employees, volunteers and agents from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by Participant while involved in the Events, other than in incidents considered to be gross negligence.
Furthermore, I/we hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in the Events.
MEDICAL TREATMENT CONSENT: I/We authorize the Organizer to any emergency 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 or emergency care facility. I agree to be liable and to pay all costs and expenses incurred in connection with such medical and dental services rendered to the Participant pursuant to this authorization.
This authorization shall remain effective through the day of _____________ 20__ , unless sooner terminated in writing.
DETAILS:
Medical Insurance: ___________________________________________
Insurance Company: __________________________________________
Policy/Group ID#: ____________________________________________
Emergency Phone Number: ___________________________________________________________
___________________________________________________________
Allergies or Medical Conditions: ___________________________________________________________
___________________________________________________________
Parent/Guardian Signatures
_______________________________/_________________________________ Date ___________