2024 Minor Waiver and Medical Consent Form

2024 Minor Waiver and Medical Consent Form
To ensure the safety and health of my child I, the parent/legal guardian of (minor’s name), agree to the release and discharge Calvary Chapel of the Chino Valley, its officers, employees, and agents, from any liability resulting from loss, injury, or damage to the named persons or property as a result of their attendance at, or participation in all church-organized functions, except the activities deemed hazardous to my child’s health/welfare per my child’s medical physician. I hereby give my consent to the physician selected by the Staff Minister (or his/her representative) to arrange for medical and dental care, and to give oral or written consent on my behalf for medical or dental treatment, including surgery deemed necessary by the licensed physician for my child named above. This authorization is given pursuant to Section 25.8 of the Civil Code of California. In consideration for being permitted to engage in church-organized functions, I agree that my child named above will abide by all expressed rules and requirements for the activities. This authorization shall remain effective for the entire calendar year unless sooner revoked in writing and delivered to Calvary Chapel of the Chino Valley.
Minor's Information
Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Grade*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Legal Guardian's Information
Name*

First NameLast Name
Phone*
Email*

Confirmation Emailexample@example.com
Emergency Contact

Other than above mentioned
Name*

First NameLast Name
Relationship to Minor*
(i.e. Grandpa, Grandma, Uncle, Aunt, Family Friend, etc.)
Phone*
Medical Information
Do you know of any health factor(s) that would limit your child's physical activity?*

YesNo
If yes, briefly explain:
To protect your child, but not exclude him/her from any church-organized function, please list any health concerns that we should be aware of (i.e. allergies to medications or insect stings, etc.).
Please list any prescribed medications your child uses, the dosage, and the reason they are taken:
*All prescription medication must be in its original container with minor's FULL NAME and dosage information in order to be administered.
Over-the-counter medication (i.e. Tylenol, cold medicine, ointment, etc.) may be administered only with a parent's consent.*

I give my consent.I do NOT give my consent.
Insurance Information
Insurance Co.*
Policy #*
Name of Policy Holder*
Signature
My signature below indicates that I hereby agree to the terms written at the beginning of this waiver and medical consent form. My signature also signifies that I have provided all truthful and pertinent information in relation to the care and well-being of my child.
Parent/Legal Guardian Name*

First NameLast Name
Today's Date*

MonthDayYear
Parent/Legal Guardian Signature*

Clear
Should be Empty:

2024 Minor Waiver and Medical Consent Form

Minor's Information

Parent/Legal Guardian's Information

Emergency Contact

Medical Information

Insurance Information

Signature