Park Hills Youth Parent/Guardian Consent Form 2021/2022

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To Whom It May Concern: The undersigned does hereby give permission for our (my) child to attend and participate in activities sponsored by Park Hills Church. By signing this form I give permission for our (my) child to participate in over-night activities, trips, off-campus activities, and riding in vehicles with Park Hills staff and processed volunteers.

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

Unless otherwise noted, we (I) release to Park Hills Church the rights to photos, video, or other media for use in church publications.
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Medical Information



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