Consent for Medical Treatment (18 & Over)

Name: *

First

Last

Age:

Birth Date:

Insurance Information:

Medical Insurance:

Insurance Company:

Policy/Group ID#:

Emergency Contacts:

Name: *

First

Last

Relationship:

Phone:

Allergies or Medical Conditions:

What medications (if any) are presently being taken?

Any History of Serious Illness (Diabetes, asthma, epilepsy, etc.) or recent hospitalizations that we need to be aware of?

Other Dietary Considerations:

MEDICAL TREATMENT PERMISSION:

In the case where I am unable to consent for my own treatment, I authorize the adult, in whose care I am in, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to me 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. 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 or youth pursuant to this authorization.

is Policy/Group Insurance

This permission is granted while participating in the following General Council Churches of God, (Seventh Day)'s Christian Youth activities:

Northwest Youth Camp
Campmeeting Youth Outing
All Christian Youth Activities

Signature

Clear Signature

Date