2018 Parental Consent Form
Family Information
Child's Name *
Your answer
M/F *
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Home/Cell Phone Number
Your answer
Work Phone Number
Your answer
Email Address
Your answer
Birthday *
MM
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DD
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YYYY
Age *
Your answer
Grade *
Emergency Contacts
Contact #1 Name *
Your answer
Contact #1 Relationship *
Your answer
Contact #1 Phone Number *
Your answer
Contact #2 Name *
Your answer
Contact #2 Relationship *
Your answer
Contact #2 Phone Number *
Your answer
In Case of Emergency:
I hereby give authorization to an adult leader of the events within this year, as agent for me, to consent to an X-ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I expect to be contacted as soon as possible.
This is also to certify, to the best of my knowledge, that the above named has no physical handicaps or illnesses (except as noted on this form). I hereby release New Hope Christian Church of Crawfordsville, IN, its staff, and sponsors from responsibility and liability for any injury or illness that the above named may sustain during church sponsored events/activities.
Electronic Signature of Parent/Legal Guardian: *
Your answer
Date Signed *
MM
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DD
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YYYY
Medical Information
Insurance Company
Your answer
Policy/Group # *
Your answer
Policy Holder's Name *
Your answer
Insurance Company Phone Number *
Your answer
Physician's Name *
Your answer
Physician's Phone Number *
Your answer
Allergies
Your answer
Medications
Your answer
Handicaps/Limitations
Your answer
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