First Baptist Church of Pontiac
9000 Highland Road
White Lake , Michigan   48386
(248) 698-1300

Parental/Legal Guardian Consent Form

Child’s Name                                                             Age                        Birthday        /       /        

Address                                                                                           Phone (         )                       

City                                                                                     State               Zip Code                   

School                                                                    Grade in or just completed                             

Parent(s) business phones                                               /                                                          

To whom it may concern:

The undersigned does hereby give permission for our (my) child,                                            , to attend and participate in activities sponsored by First Baptist Church of Pontiac on _____________________ (Dates of event). 

We (I) authorize an adult, in whose care the minor 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 the minor under the general or special supervision and on the advice of any physician or dentist 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.

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 the aforesaid agents 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.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

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 First Baptist Church of Pontiac.

Hospital insurance                     Yes                      No

Insurance company                                                      Policy number                                         

Emergency phone numbers                                                                                                        

Signed                                                                                        

Date                                            

Please list below any specific medications, allergies, or special medical problems your child may have.  Thank you.