Medical Minor Consent Form

THIS FORM MUST BE COMPLETED FOR EACH CHILD, AGE 0-18 YEARS.
FIRST-AID CLINIC
Consent to Treat Minor Patient-Without Parent/Legal Guardian Present

By law, any child under the age of 18 years old cannot be seen by a nurse/doctor without consent from a parent or legal guardian.
Minor's Name*
Minor's Date of Birth*

MonthDayYear
Date
For those occasions when you may not be with your child, please list those individuals who may give us consent to see your child:
Adult Name 1*
Relationship to Child*
Phone Number*

Area CodePhone Number
Adult Name 2
Relationship to Child
Phone Number

Area CodePhone Number
Adult Name 3
Relationship to Child
Phone Number

Area CodePhone Number
It is always recommended that a consenting adult accompany a minor when receiving medical care but in the event of an emergency; consent may be given to provide 1st aid or emergency care to the minor child.
Allergies
Do you wish to give consent for the minor to receive medical care without an accompanying adult?*
Authorization Agreement
Parent/Legal Guardian Name Authorization*
Phone*

Area CodePhone Number
I __________ Request and authorize The First Aid Clinic at Family Camp and its personnel to deliver first-aid medical care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of the minor child. I have read, understand, and give my consent as stipulated above. My signature means that I have read this form and understand this form.
Parent or Legal Guardian Name*
Relationship to Minor*
Parent or Legal Guardian Signature*

Clear
Date Submitted*

MonthDayYear
Date
Please submit this form for each child
Should be Empty:

THIS FORM MUST BE COMPLETED FOR EACH CHILD, AGE 0-18 YEARS.

FIRST-AID CLINIC

Consent to Treat Minor Patient-Without Parent/Legal Guardian Present

For those occasions when you may not be with your child, please list those individuals who may give us consent to see your child:

It is always recommended that a consenting adult accompany a minor when receiving medical care but in the event of an emergency; consent may be given to provide 1st aid or emergency care to the minor child.

Authorization Agreement

Please submit this form for each child