Medical Release Form - Ponderosa Basin Chapel
Authorization to Consent to Medical Treatment of minor child during Parent's/Legal Guardian's Absence

I, the undersigned, parent or legal guardian of the below child/Minor, hereby consent to his or her full participation in the activities and trips of Ponderosa Basin Chapel. I understand that accidents do happen, and here by generally release Ponderosa Basin Chapel and its pastor, youth coaches, and other employees, agents and representatives from any liability or other legal or financial responsibility for any accidental injury to the below named child/minor while he or she is under the supervision of such person(s).

In the event of any such accident or other situations in which the below-named child may require emergency medical or dental care, I hereby authorize any pastor, youth coach, or other employee, agent or representative of Ponderosa Basin Chapel, in my absence, to seek out and consent to any necessary medical or dental care for the below-named child/minor; and further authorize any physician, dentist, other medical personnel, or health care facility to rely on such consent and perform any necessary medical or dental care, including, without limitation, x-ray, and other diagnostic procedures, administration of anesthetic or medication, and surgery; and hereby ratify and confirm whatever consent to medical or dental care that may be given hereunder.
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Child's First and Last Name *
Relationship to Child *
Child's Date of Birth *
Child's Grade *
Your phone number in case of Emergency *
Child's Physician Name and Number
Any Information Regarding Medical Insurance *
Current Medication
Digital Signature of Parent/Legal Guardian - (Print Full Name) *
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