Medical Authorization Form

Youth Medical Authorization Form

BOLCC Sports Ministry
Participant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
5-18
Participant Address

Street Address

Street Address Line 2

CityState

Zip Code
School
Grade
To Whom It May Concern
The undersigned does hereby give permission for our (my) child First Name Last Name to attend and participate in activities sponsored by Breath of Life Christian Center's Sports Department. Date

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to transportation to a hospital/medical facility, 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(s) to pay all cost and expenses incurred in connection with such medical and dental services rendered to the aforementioned youth pursuant to this authorization.
YesNo
Insurance Provider
Hospital to take your child to in the event of an emergency:
Name and Address
Primary Physician Name:

First NameLast Name
Physician's Phone Number
Please enter a valid phone number.
Known Allergies or Medical Concerns:
Emergency Contact Information
Contact 1 Name

First NameLast Name
Contant 1 Relation
Contact 1 Phone Number
Please enter a valid phone number.
Contact 1 Email
example@example.com
Contact 2 Name

First NameLast Name
Contact 2 Name
Contact 2 Phone Number
Please enter a valid phone number.
Email
example@example.com
Parent Signature*

Clear
Should be Empty:

Youth Medical Authorization Form

Emergency Contact Information