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Parental Consent Form |
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Name Age Birth date
Address Phone --
City State Zip Code
School Grade in or just completed
Church you attend Date Baptized
Parents Names (printed) Business Phone --
Parents Names (printed) Business Phone --
To whom it may concern:
The Undersigned does hereby give permission for our (my) child, , to attend and participate in events sponsored by Tyro Christian Church.
We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to rendered to the minor under the general of special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for our (my) Child to return home due to medical reasons, behavioral problems or otherwise, the undersigned shall assume all transportation costs.
The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Tyro Christian Church. We (I) will have done any school work done on time and will not use absence as an excuse. We (I) give Tyro Christian Church permission to use photo and video taken in promotional use. We (I) understand that no form of tobacco, alcohol, or any other illegal substance will be permitted.
Hospital Insurance Yes No Insurance Company
Participant date Policy Number
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| Emergency Phone Numbers | Father G | date |
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| Emergency Phone Numbers | Mother G | date |
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| Emergency Phone Numbers | Legal guardian G | date |
On the reverse side of this page, please list any allergies, special medical problems, or special housing/transportation concerns your child may have. Thank You.
“By utilizing this form, TCC will use the typed signature the same as a written signature on this form. If the signature is typed it may be turned in by a parent or legal guardian only. We encourage you to still print this form out and sign it.”
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