Youth Parent Consent and Medical Form - HOPE Presbyterian Church

Your name *

Email address *

Household members

CHILD NAME: Click "Add Child' and complete the form for one child. Sending two or more kids? Complete and submit for EACH child. 1 form = 1 child.
PARENT (S) NAME (S): Click "Add Adult" and and 1 or 2 parent/guardian names of above child.

Emergency Contact if neither parent/guardian above can be contacted (Full Name) *

Emergency Contact Phone Number *

Relationship to the child *

ADMINISTERING MEDICATION PERMISSION

Medication(s) my child needs or might need while out of my care. PLEASE SEND AN AMPLE SUPPLY OF YOUR REGULAR MEDICATION WITH YOUR CHILD TO THE EVENT. SEND ALL PRESCRIPTIONS IN ORIGINAL, LABELED CONTAINER!

My child has medication they need to take (or be ready to take) during this trip/event. *

Yes

MEDICAL HISTORY OF THE CHILD

Date of last Tetanus shot *

Please check all that apply:

Allergies/Hay Fever

Asthma

INSURANCE INFORMATION

Parent or Guardian’s Insurance Company *

Insurance Policy Group Number (if no group number put "0000") *

Insurance Policy Member Number *

This form is current for a period of one year from date signed accompanied by an Event Permission Form

Parent/Guardian Signature

By signing my name below, I agree and understand that by signing the this Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature. I further agree my signature on this document is as valid as if I signed the document in writing.

Parent/Guardian Electronic Signature *

Additional Comments

Please use this section to inform of any details this form may not have covered regarding your child.