Parent Consent to Treat Minor Form (Completed annually and taken on each trip)

Being the parent or legal guardian of __________________________________________, I, _______________________________________, do consent to any x-ray, anesthetic, medical, surgical, or dental diagnosis or treatment that may be deemed necessary for my minor child. Further, I understand that all efforts will be made to contact me prior to treatment. In the event I cannot be reached in an emergency, I give permission to the attending physician to treat my minor child. I further understand that the doctors, dentists, and other providers attending to my child will take all reasonable safety precautions during their care.

Further, as parent or legal guardian I am responsible for the healthcare decisions for my minor child and agree that my insurance plan is the primary plan to pay for the dental, medical, or hospital care or treatment that is given to my child. Any policy of the church or organization sponsoring this event will be used as the secondary coverage.

Minor's Date of birth: _____________________

Parent/Guardian Signature: ________________________________ Date: ____________

Emergency Numbers: ________________________________________________________

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The Power Place 108 church alley, Kennett Square Pa. 19348

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Parent Consent Form to Hold Harmless (Completed for each offsite event)

Activity: __________________________________________________________________

Child's Name(s): ___________________________________________________________

Age:________________ Birth date: _____________ Sex: _______________________

Address: __________________________________________________________________

Phone Number: ____________________________________________________________

I, _____________________________________, being the parent or legal guardian of _______________________________________, have been informed of the above activity sponsored by The Power Place of Kennett Square Pennsylvania, hereby give my consent for my minor child to participate in this activity.

I understand that all reasonable safety precautions will be taken by the leaders of this activity, and that the possibility of an unforeseen hazard does exist. I further agree not to hold The Power Place of Kennett Square Pennsylvania, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the minor(s) listed on this form.

My minor child is to be excluded from the following activities due to health conditions listed below: ____________________________________________________________________

Signature of parent or guardian: _______________________________________________ Date signed: _________________________

The Power Place 108 church alley, Kennett Square Pa. 19348

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