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: ________________________________________________________________________________

________________________________________________________________________________

_________________________________________________________________________________

_______________________