Synod Authorization for Medical Care of Participant

Arkansas-Oklahoma Synod Authorization for Medical Care of Participant

For Calendar Year 2026
I, the undersigned parent or legal guardian of First Name* Last Name* , a minor child, DO HEREBYAUTHORIZE TO CONSENT to any x-ray examinations, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care to be rendered to the above named minor under general or special supervision and upon advice of a physician, surgeon or dentist licensed under the laws of the states of Arkansas and Oklahoma.
IN GIVING THIS CONSENT I RECOGNIZE AND UNDERSTAND that in situations where the above named minor requires immediate medical or hospital care, it may not be possible to contact me. In such situations, I will not be able to knowledgeably evaluate the risks attendant upon each, and the risks attendant to foregoing all treatment; in such situations, I authorize a physician, surgeon or dentist to exercise his/her professional judgment and assess the risks incident to and choose the necessary treatment from any available alternatives and to render such care and perform such treatment as he/ she in his/her professional judgment determines to be necessary for the health and safety of the above named participant.

I also understand this covers consent for all activities for the above named minor through the ArkansasOklahoma Synod Lutheran Youth Organization. This authorization will be in effect from January 1, 2026 to December 31, 2026. It is my responsibility to make updates and changes as necessary.

This authorization may be revoked at any time with notice in writing to Becca Middeke-Conlin, Bishop, Arkansas-Oklahoma Synod, and the Evangelical Lutheran Church in America.
Parent/Guardian Signature
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
First Parent's Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Email
example@example.com
Second Parent's Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Email
example@example.com
- Emergency Contact Name
  
  First NameLast Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Contact's Relationship to Youth
- Insurance Carrier's Name
- Policy Number
- Insured’s Name
  
  First NameLast Name
- Insured’s Relationship to Minor:
- Physician’s Name:
- Physician's Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Participant’s birth date:
  
  MonthDayYear
  Date
- Date of last Tetanus shot:
- List any known allergies and reactions:
  enter None if this does not apply.
- List medications participant is currently taking including frequency:
  enter None if this does not apply.
- Participant’s pertinent medical history:
- Please provide a copy of the front and back of the insurance card. This copy will remain in confidence with this form until the end of the calendar year or until changes are made by you.
  
  Cancelof
Should be Empty:

Arkansas-Oklahoma Synod Authorization for Medical Care of Participant