Transportation And Medical Release Consent Form For Minor Child printable pdf download

Transportation And Medical Release Consent Form For Minor Child

Transportation and Medical Release Consent Form For Minor Child

The undersigned, give the following minor child permission to be transported by any

variety of means that the Western Iowa Synod—ELCA deems appropriate as part of

his/her participation in the Western Iowa Synod—ELCA Companion Synod trip to

Tanzania program.

As a parent and/or guardian, I hereby authorize and direct that the synod group leaders,

Cynthia Wells and/or Pr. Paul Rothfusz, arrange any necessary medical treatment or

transportation for the following minor child in the event of a medical or dental emergency

which, in the opinion of the attending physician, may endanger his or her life, or cause

disfigurement, physical impairment, or undue discomfort if delayed. The authority is

granted only after a reasonable effort has been made to reach me.

My child is subject to the following allergies or medical conditions, and I authorize the

Church to disclose such allergies or medical conditions to a licensed medical doctor in

the event my child should require emergency medical or dental care (please describe

allergies, blood type, and/or medical conditions with specificity):

Name of minor:_______________________________ Relationship:_________________

Dates when release is intended:______________________________________________

This release form is completed and signed of my own free will with the purpose of

disclosing medical information and of authorizing transportation and medical treatment

under emergency circumstances in my absence.

____________________________________________

_______________________

Signed

Date

___________________________________________

_______________________

Address

Phone

___________________________________________

________________________

Family Physician

Phone

Other contact in case of an emergency:

_______________________________

___________________

____________

Name

Relationship

Phone

Transportation And Medical Release Consent Form For Minor Child