Chimacum Middle School » Medical Consent Form

Consent For Medical Treatment of a Minor

Student’s Name _______________________________Grade ____________

Date of Birth _____________________

I, _______________________________ declare that I am the
(full name of parent/guardian)

________________________
(Father, Mother, Guardian)

of ______________________________
(Student’s Name)

I hereby authorize the staff/coaches of the Chimacum Middle School, located in Jefferson County, State of Washington, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care necessitated by injury or illness while the above named student is attending a practice/game/meet. Such treatment is to be rendered to the minor under the general or special supervision and on the advice of a physician or surgeon licensed to practice in the State of Washington. I hereby waive and release the school from any and all liability for injuries or illness incurred while participating in practice or a game or meet. I hereby certify that I have read and fully understand this authorization.

Date __________________

Parent or Guardian Signature ______________________________

Insurance Company ____________________________

Home Phone Number _____________________

Cell # ______________________

Emergency Name ________________________

Emerg. Phone _______________

Family Physician _________________________

Physician Phone _____________

Medical conditions, medication information or allergies the physician should be aware of:

________________________________________________________________________________