PARENTAL CONSENT AND EMERGENCY TREATMENT FORM
 
Name of minor *
Address
City
Zip
Birthdate
(mm/dd/yyyy)
Phone
 *
Email
To whom it may concern,        
 
The undersigned does hereby give permission for our (my) child,
to attend the activities and events of the Wiley Association of Youth (WAY) from
January 1, 2009 to December 31st, 2009.
We (I) authorize an adult, in whose care my child has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to my child under the special or general supervision of any licensed physician or dentist, 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 any services rendered to the aforementioned minor pursuant to this authorization, including transportation costs, if any.
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 the Wiley Association of Youth.
Father's Name
Mother's Name
Legal Guardian
 
EMERGENCY INFORMATION
Insurance Company
Policy Number
Preferred hospital (name/town)
Family Physician
Address
Phone *
Allergies
Medical Conditions
Medications