CONSENT FORM

 

This form should be in the possession of the group leader from day of departure to day of return from the event. Form must be completed by parents/guardians of participants under 21 years old.  Parent/Guardian signature must appear below of your child will not be permitted to attend the Event.

 

(I) (We), the undersigned parent(s) and / or legal guardian(s) of ______________________, a minor (under the age of 21), do hereby authorize my child’s congregational youth leader, (and/or any other adult appointed or designated by him/her) to consent to medical, surgical and dental care for such minor child, (ii) consent to any diagnostic tests, medical, surgical or dental procedure or treatment as may be considered therapeutically necessary by the physician, surgeon, dentist or other health care personnel providing care for such minor child, and (iii) on (my) (our) behalf, to (a) employ physicians, surgeons, dentists, nurses and other health care personnel as may be deemed necessary for such minor child, (b) admit such child to any hospital, clinic, emergency room, laboratory or other health care or diagnostic facility for examination, treatment, surgery or care and ( c ) sign all necessary consent and authorizations.

 

It is understood that this authorization is given in advance of the occurrence of any condition or situation that would necessitate any such medical, surgical or dental care being required, but is given to provide authority to obtain such care if it should be required. I fully understand the consequences of the foregoing statements and sign this AUTHORIZATION TO CONSENT TO MEDICAL AND DENTAL CARE knowingly, freely and willingly.

 

This authorization shall continue for such time as my child is participating in the Lutheran Youth Fellowship of Emmanuel events and during travel to and from this event.

 

IN WITNESS WHEREOF, (I) (We) have executed this “Authorization to Consent to Medical and Dental Care” this ________ day of ____, 20__.

_____________________       _____________________

Parent/Legal Guardian       Parent/Legal Guardian

 

STATE OF (__________________)

         (__________________)

COUNTY OF(__________________)

 

On this ________ day of ____________, 2006, before me, a Notary Public, personally appeared and, known to me to be the person(s) who executed the above consent and stated that it was executed as his/her (their) free act and deed.

 

 

(SEAL)                                     __________________

                                            Notary Public

 

 

My Commission Expires:  ___________

NAME:_________________________________________________________________

     (LAST)                  (FIRST)                  (MIDDLE INITIAL)

 

MEDICAL INFORMATION

 

EMERGENCY AND HEALTH INFORMATION (To be read and completed by parent):

General: Does participants have: (if “yes” - explain)

 

__Yes __NO  ALLERGIES?_________________________________________________

__Yes __NO  Heart Condition?__________________________________________

__Yes __NO  Other?____________________________________________________

 

Is participants subject to: (If “yes” - explain)

__Yes __NO  Headaches?________________________________________________

__Yes __NO  Seizures?_________________________________________________

__Yes __NO  Motion Sickness?__________________________________________

__Yes __NO  Fainting?_________________________________________________

__Yes __NO  Sleep Walking?____________________________________________

__Yes __NO  Upset Stomach?____________________________________________

__Yes __NO  Other?____________________________________________________

 

Does participants have reaction to: (if “yes” - explain)

 

__Yes __NO  Bee Sting?________________________________________________

__Yes __NO  Penicillin?_______________________________________________

__Yes __NO  Other Drugs?______________________________________________

__Yes __NO  Poison Ivy, Oak, Sumac?___________________________________

__Yes __NO  Other?____________________________________________________

__Yes __NO  Has the participant had any serious illness or surgery within the past 10 years?

            Please list:_____________________________________________

__Yes __NO  Does the participant have any condition that would prevent him/her from participating in any event activities?

            Please list:______________________________________________

__Yes __NO  Does the participant take any prescription medication?

            Please list:______________________________________________

__Yes __NO  Are any drugs ineffective in treatment?

            Please list:______________________________________________

__Yes __NO  Is the participant diabetic? Medication?__________________

__Yes __NO  Does the participant have any sight or hearing impairment?

__Yes __NO  Does the participant wear contact lenses?

__Yes __NO  Does the participant wear hearing aids?

           

Blood type:______ Date of last tetanus shot:_____/______/_______

 

A current tetanus shot is required.  After 5 years, another tetanus shot is recommended.

 

Please indicate ANYTHING else that leaders should know to help avoid or deal with any situation that might arise:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Participants Name: (Last)_____________________(First)_________________

Birth Date:___/____/____Male:_____Female:_____SS#_____________________

Home Address:_________________________________________________________

City/State/Zip:_______________________________________________________

Home Phone: (____)______________  Day Phone: (____)_______________

Custodial Parent/Guardian: ___________________________________________

Home Phone: (____)______________  Day Phone: (____)_______________

Home Address (if Different):__________________________________________

Health Plan Carrier: _________________________________________________

Name of Insured:______________________________________________________

Relationship to participant: _________________________________________

SS# or policy holder or insurance ID number:__________________________

Family Doctor: _______________________________________________________

Office Phone: (____)__________________ Medical Exchange: (___)________

Family Dentist: (___)_________________ Office Phone: (____)___________

Second Parent or Emergency Contact Person: ___________________________

Relationship to participant: _________________________________________

Home Phone: (____)_________________ Day Phone: (____)_________________

 

Please specify if any health insurance pre-certification, notification, or other requirements exist for the participant: ______________________________________________________________________

 

Participants will be covered by a limited accidental death and accidental bodily ___________________________________________that provides reimbursement up to                  for medical expense incurred as the result of purely accidental injuries sustained while at any Lutheran Youth Fellowship Event.  This coverage is secondary to all other insurance coverage available to the participant and will make payment only if such other insurance (participant’s primary policy) is not adequate to cover the medical expenses resulting from an accidental injury sustained while a Lutheran Youth Fellowship Event.