Minor Participation Authorization and Consent to Emergency Medical Treatment Form

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Lombard Church of the Nazarene Lombard, IL 60148

Email *

I, the undersigned, certify that I am the parent or legal guardian of the minor child (hereafter the “minor child”) *

Type the name of your child below.

I consent for the minor child to participate with the Lombard Church of the Nazarene activity (hereafter “the activity”) *

Type the name of the activity below:

On the following date(s) or during the timespan of: *

Type the date(s) below:

I recognize that there are risks involved in participating in this activity and hereby assume all risk of injury, harm, damage, or death to my minor child in connection with his/her participation in this activity. To the fullest extent permitted by law, I release Lombard Church of the Nazarene, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless Lombard Church of the Nazarene, its trustees, officers, directors, employees, agents and representatives from any claims arising out of my minor child’s participation in the activity (Initial below). *

If you agree to these statements, initial below.

Further, being the parent or legal guardian of the minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor child. I understand that efforts will be made to contact me prior to treatment but, in the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor child. As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child. Any insurance policy of the church or organization sponsoring this event will be used as the secondary coverage *

If you agree to these statements, initial below.

If you agree to all of the statements and conditions in this form, sign this form electronically. *

Type Your Name (as a signature) and the date below.

Emergency contact number(s) *

Include any phone numbers you would like us to call in the case of an emergency.

Please provide any additional information about your child that is important for the leaders to know (if applicable)

Send me a copy of my responses.

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