2022 Parental Authorization Consent Form
Name of Student
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
The undersigned do hereby authorize Matt Reagan and/or Spencer Willis, Leadership Project Directors, or such substitute as they may designate as agent for the undersigned to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above student which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon, licensed under the Provision of Medicine Practice Act or of any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital or elsewhere. Further, the undersigned agrees that East Cooper Baptist Church of Mt. Pleasant, SC, or any subdivision thereof, shall be held harmless from any liability for damages to person or property to the student named herein that might arise out of, in route to, in route from, while in residence, or as a result of, any involvement or participation by said minor in a program or activity of East Cooper Baptist Church, or subdivision thereof. This authorization, consent, and waiver of liability will remain effective, unless revoked in writing by the undersigned, and delivered to the aforesaid agent.
Parent/Guardian Signature
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Date
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Month
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Day
Year
Date
Parent/Guardian Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Insurance Company Name and Address
*
Policy Number
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Insurance Company Number
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Please describe any special medications and/or medical information that would be necessary or helpful:
Submit
Should be Empty: