PV Off-Campus Consent Form for Minors

Pleasant Valley Church of Christ
10900 Rodney Parham, Little Rock, AR 72212, (501) 225-5818
Parental Consent Form and Authorization for Medical Treatment of Minor

I, the undersigned parent or guardian of the child/children listed below, a minor (the “Child”), hereby authorize adult workers with the youth ministry of Pleasant Valley Church of Christ (“PVCC”), as agent(s) for the undersigned, to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care for the Child that is rendered under supervision of any physician or surgeon 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.

Further, as parent or guardian of the Child, I hereby expressly consent that the Child may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold harmless any physician, hospital, or other medical center for rendering such services.

Further, as parent or guardian of the Child, I hereby expressly consent that the youth ministry of PVCC may use video, photographs, audio recordings, and any other visual or audio reproductions of the Child that may be taken during the activities, classes, and other events of the youth ministry for all uses approved in the sole discretion of PVCC, including but not limited to the posting of such video, photographs, audio recordings, or other visual or audio reproductions on the PVCC website and social media accounts.

This form is valid for 12 months from date filled out. Information shared with members of the children’s ministry will be maintained in the strictest circle of confidence allowed by the information.

Date*
MM slash DD slash YYYY
Parent/Guardian Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Preferred Phone*
Alternate phone in case of emergency*
Insurance Company Name*
Insurance Policy Number/Medicaid Number*
Group Number
Child's Information*
Name Age Physician
Please list any medications your child is taking.*
If child is taking medications on this trip, who will administer the medication?
- Child can self administer meds
- Adult or sponsor will administer meds
Please list and explain any allergies (including allergies to medications).
Please list any other information that may be needed in an emergency.
Signature: Please write full name to serve as signature*

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Name	Age	Physician