Youth Consent for Medical Treatment

Repeater

Name of Youth: *

First

Last

Birth Date:

Age:

Insurance Information:

Medical Insurance:

Insurance Company:

Policy/Group ID#:

Emergency Phone #s in case parent/guardian cannot be reached:

Allergies or Medical Conditions:

Name: *

First

Last

Relationship:

Phone:

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: We (I) authorize an adult, in whose care the minor has been entrusted, to consent 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. 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.

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

Insurance: Insurance that

Signature

Clear Signature

Date