Minor Participation Authorization and Consent to Emergency Medical Treatment
I, the undersigned, certify that I am the parent or legal guardian of
(hereafter the “minor child”). I hereby give my consent to have my minor child participate in the youth activities organized and executed by Aletheia Church (Harrisonburg, VA).
I recognize that there are risks involved in participating in these activities and hereby assume all risk or 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: the Church and its staff, elders, and volunteers 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: the Church and its staff, elders, and volunteers from any claims arising out of my minor child’s participation in the activity.
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 leaders 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 of 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.
Executed this day,
Signed (type name)
Physical Address
Email *
Address *
Phone number
Name of Student
Student Grade
Birth Date
Student Address
Parent Name
Parent Address
Parent Email
Parent Phone
In Case of Emergency, please notify:
Notification Phone:
Relationship to Minor:
Health Insurance Company:
Policy Number:
Family Physician:
Physician Phone:
Current Medication
Check any boxes that apply:
Any other pertinent information:
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