2025 Medical Consent

North County Church of Christ

Parent Consent for Medical Treatment for:

Name of Student

First Name

Last Name

Parent/ Guardian's Name

First Name

Last Name

Do You Have Medical Insurance?

The above parent or guardian of the above named minor, herein authorizes any North County Church of Christ representative bearing this written authorization to consent to medical or dental treatment should it become necessary, by a licensed and qualified physician or dentist. This written consent authorizes any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician or surgeon licensed under the provisions of the American Medical Association or equivalent governing body constituted by the foreign government, whether in the United States, its territories or in a foreign country. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, and is given to provide authority and power on the part of said representative person to give specific consent to any and all such diagnosis, treatment or hospital/dental care which the aforementioned physician or dentist in the exercise of his best judgment may deem advisable. This authorization shall include transportation to receive the medical or dental care. It is understood that the possession and administration of the above minors’ personal medicine is the minor’s responsibility. The undersigned herein authorizes the North County Church of Christ representative to administer over-the-counter medications such as Tylenol, Pepto Bismol, Cough medicine, allergy medicine, etc., if it is determined that the minor is in need of such treatment for comfort and/or relief of symptoms. It is understood that the undersigned agrees to reimburse the North County Church of Christ for any expenses incurred in any medical, surgical or dental treatment. It will not be necessary to reimburse the church for cost of over-the-counter medications as mentioned above.

Physician's Name

First Name

Last Name

Physician's Phone

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Physician's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Insurance Company

Subscriber

Policy Number

Liability Release

It is understood that if the North County Church of Christ representative determines that the above-named minor becomes too ill to remain at the function/event or if the director determines the minor’s behavior is a continual problem, the undersigned agrees to pick up the minor from the specific event as soon as possible after being contacted by the staff. LIABILITY RELEASE: It is understood that the undersigned does also give permission for the above named minor to ride in any vehicle designated by the adults in whose care the minor has been entrusted while attending and participation in activities sponsored by the North County Church of Christ. Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree not to hold North County Church of Christ or its employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both medical and liability release. This authorization will remain in effect from January 1, 2025 through December 31, 2025

Today's Date

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