Free Parental Permission Medical Consent & Liability Release
This Parental Permission Medical Consent and Liability Release is signed by a child’s parent or guardian and gives permission for the child to participate in an organized event. This consent sets out child’s name, age, birth date and school, parent or guardian’s name and phone number and details regarding child’s medical insurance. When signed, this Parental Permission Medical Consent also gives event organizer the authority to authorize any emergency medical treatment deemed necessary for the child.
Disclaimer:This was not drafted by an attorney & should not be used as a legal document.
Parental Permission Medical Consent and Liability Release
CHILD’S NAME: ____________________________
BIRTH DATE _______________________________
SOCIAL SECURITY# ___________________________
TO WHOM IT MAY CONCERN:
I/We, of _____________________________________________________ the parent(s) or legal guardian(s) of the Participant do/does hereby give permission for the following child: _____________________________________________________ ____________________________________ (“Participant”), to attend and participate in sports, events, and retreats (“Events”) held by _____________________________________ (“Organizer”) during ____________________________ to _____________________________.
In consideration of Organizer allowing the Participant to participate in the Events, I/we do hereby release, forever discharge and agree to hold harmless Organizer, its directors, employees, volunteers and agents from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by Participant while involved in the Events, other than in incidents considered to be gross negligence.
Furthermore, I/we hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in the Events.
MEDICAL TREATMENT CONSENT: I/We authorize the Organizer to any emergency 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 or emergency care facility. I agree to be liable and to pay all costs and expenses incurred in connection with such medical and dental services rendered to the Participant pursuant to this authorization.
This authorization shall remain effective through the day of _____________ 20__ , unless sooner terminated in writing.
Medical Insurance: ___________________________________________
Insurance Company: __________________________________________
Policy/Group ID#: ____________________________________________
Emergency Phone Number: ___________________________________________________________
Allergies or Medical Conditions: ___________________________________________________________
_______________________________/_________________________________ Date ___________