Parental Consent/Medical Treatment Form
Please fill out this form and click submit.
Event Name
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Student's Name
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Parent or Guardian Name
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Email Address
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This address will receive a confirmation email
Emergency Contact Phone
*
Address
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I, the above signed parent or guardian of above named minor I do hereby authorize adult workers with the minor of Lifepoint Assembly of God to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon 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.
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Please select all that apply.
Yes
No
Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for rendering such services.
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Please select all that apply.
Yes
No
I release Lifepoint Assembly of God and the Louisiana Assemblies of God from any and all liability in connection with this trip.
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Please select all that apply.
Yes
No
Insurance Company or Group
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Policy Number
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Name of Insured
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By signing and submitting this form I hereby give witness to proper completion of this form by the minor's parent or guardian. And also will serve as your digital signature.
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Submit
Description
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