Child Medical Consent Form

Child Medical Consent Form

Light & Truth School Ministries
Parental Information
Parent/Guardian 1

First NameLast Name
Phone Number of Parent/Guardian 1
Email Address of Parent/Guardian 1
example@example.com
Address of Parent/Guardian 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent/Guardian 2

First NameLast Name
Phone Number of Parent/Guardian 2
Email Address of Parent/Guardian 2
example@example.com
Address of Parent/Guardian 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Child

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Consenting Party
Name of Person/Organization
Address of Person or Organization
Child's Medical Information
Blood Type
Food Allergies (Please Specify)
Drug Allergies (Please Specify)
Name of Pediatrician
Phone Number of Pediatrician
Insurance
Policy Number
Effectivity Period
Date Start

MonthDayYear
Date
Date End

MonthDayYear
Date
I/We, {nameOf4} and/or {nameOf23}, hereby declare that I am/We are the parent(s)/legal guardian of {nameOf}, who was born on the {dateOf}.

I/We do hereby consent to my child's medical care and the administration determined by a physician to be necessary for the welfare of my/our child while said child is under the care of {nameOf29} of {addressOf}.

This authorization shall be effective from {dateStart} until {dateEnd}.
Signature of Parent/Guardian 1

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Signature of Parent/Guardian 2

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Date signed

MonthDayYear
Date
Date signed

MonthDayYear
Date
Should be Empty:

Child Medical Consent Form

Parental Information

Consenting Party

Child's Medical Information

Effectivity Period