Health Care Consent for Minors

Health Care Consent for Minors

Each parent or guardian must fill out the information below completely for each individial child. This form will be kept on file as a medical release. If your medical or insurance information changes, please contact the church office at (217) 367-9918 or submit another online form to update your information.
Student's Name *

First Name Middle Name Last Name Suffix
Gender *

Female Male
Date of Birth *

Month Day Year
Date
Age *
Grade *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
List any Allergies your Child has:
Parent / Guardian Name *

First Name Middle Name Last Name Suffix
Cell Phone Number *

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Emergency Contact (If parents cannot be contacted) *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Release

I certify that I am the custodial parent having legal custody of the minor listed in this form. I authorize Faith Baptist Church in whose care the minor has been entrusted to do any acts which may be necessary or proper to provide for emeregency health of the minor child on behalf of the parent, legal guardian, or person having legal custody of the child, including, but not limited to, the power: 1) To provide for such health care at any hospital or other instituition, or the employing of any physician, psychiatrist, dentist, nurse, or other person whose services may be needed for such health care and..2) To consent to and authorize any health care, including administration of anesthesia, X-ray examination, performance of operations, and other procedures by physicians, dentists, and other medical personnel except the withholding or withdrawl of life sustaining procedures.The undersigned shall be immediately notified of the child of medical care being provided on his or her behalf. This consent shall be effective from the date of execution unless specifically rescinded by either party. I do hearby agree to hold Faith Baptist Church and their agents and employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my/our child or property, even injury resulting in death, which I now have, my minor child has, or which may arise in the future in connection with any medical treatment deemed necessary and authorized by the agents and employees of Faith Baptist Church in their exercise of the terms of this Health Care Consent form. By signing here I, I indictae that I have the understanding and capacity to communicate health care decisions and that I am fully informed as to the contents of this document and understand the full import of thsi grantof powers to the staff and agents of Faith Baptist Church. I further state that I have carefully read the foregoing authorzations to consent to health care for minors and indemnification agreement and know the contents thereof and I sign hereunder as my own free act.
Signature *

Parent / Guardian Clear
Submitted Date *

Month Day Year
Date
Should be Empty:

Health Care Consent for Minors

Release