Parental Consent Form

Broadway Christian Church Youth Group

Name ______________________________  Age __________  Birth Date _______________

Address __________________________________  Home Phone (______) ______________

City ________________________  State ________  Zip Code _________________________

School ___________________________________   Grade in / just completed ____________

Parent’s name(s) _________________________        Alternate phone ____________________

Other __________________  Relationship ______________  Phone ____________________

Yes            No       My child’s photo may be used on the church website and/or in print.

To Whom It May Concern:

The Undersigned does hereby give permission for our/my child, _________________________,

(Name of Child)

to attend and participate in the _____________________________________ event sponsored by

(Event)

Broadway Christian Church on  __________________.

    (Date)

We/I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. 

The undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Should it be necessary for our/my child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

The undersigned does also hereby give permission for our/my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Broadway Christian Church.

On the reverse, please list learning disabilities, allergies or special medical needs your child may have.  Thank you!