Child Name:                                                                          Date of Birth:                       

Social Security #                                              Grade:                       


City:                                 State:           Zip:                                 

Home Phone: (     )                                 Work Phone:(     )                                       

Parental Consent:

(I) (We), the undersigned, parent(s) of                                       ,a minor, do hereby consent to said Minor participating in                                                             (explain activity) conducted by                                                                 .

Authorization of Consent to Treatment of Minor:

(I) (We), the undersigned, parent(s) of                                               , a minor, do hereby authorize                                     , hereinafter “Agent”, for and on behalf of the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital, during all times that the Minor is in the presence of said Agent.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis,  treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable.

This authorization shall remain effective through the       day of                                     , 20     , unless sooner terminated in writing.

Release of                                                                               shall indemnify, hold free and harmless, assume liability for, and defend                                                           , its agents, servants, employees, officers, and directors from any and all liability for personal injury or property damage and costs and expenses including but not limited to, attorney’s fees, reasonable investigative and discovery costs, court costs, and all other sums for any claim or action founded thereon, arising or alleged to have arisen out of               ___        (child’s name) use of the real or personal property belonging to or used by Agent while Minor is in the presence of Agent.

Parent_________________________        Date: ______________

Parent_________________________       Date: ______________

Home Phone                                      Work Phone                                             

Other phone number                                                                                              

Legal Guardian                                                     Phone                                  

Other Emergency Contact                                                Phone                                 

Family Doctor                                                                     Phone                                    

Insurance Co.                                                              If None Please Check _____

Insurance Policy Name and #                                                                                         

Known Medical Conditions






Last Tetanus Immunization?                                                                

Will You Allow Blood Transfusions? (__) Yes    (__)  NO


State Specific Parental Permission Forms

–For State Specific Parental Permission Forms you can download in Word format, go to

Inside Liability