Please print the following form, fill in your information and give to Greg or Amy Nash.

Parental Consent Form

 Name  _____________________________  Age  _________  Birthdate  ______________ 

Address  ________________________________________  Phone  _________________________ 

City  _____________________  State  __________________________  Zip  ______________ 

School  ____________________________________________  Grade  ___________________ 

Parent(s) Business Phone:  Mother  _____________________                                 
                                         Father  ______________________ 

To whom it may concern:

The undersigned does hereby give permission for our (my) child, _________________________,

To attend and participate in activities sponsored by the Fayetteville Church of Christ on the date ofWe (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. 

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

Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. 

The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult whose care the minor has been entrusted while attending and participating in activities sponsored by the Fayetteville Church of Christ.
 

Father  _______________________________  Date  __________________
 

Mother  ______________________________  Date  __________________
 

Legal guardian  ________________________________  Date  _____________

Hospital Insurance Coverage   [ ] Yes      [ ] No

 Insurance Company  ________________________________________ 

Policy Number  _________________________________ 

In case of emergency, whom do we contact first? 

(1)    _____________________________________________________________________________
                       Name                                           Relationship to child                          Phone Number

 (2)    _____________________________________________________________________________
                       Name                                           Relationship to child                          Phone Number

 Please list any allergies or special medical conditions your child may have: 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

Name of Physician  ________________________________ 

Physician's Phone  _____________________________ 

Thank you for your cooperation.