CHURCH OF THE HOLY CROSS

Medical Emergency Consent Form

For the purpose of (event):

Date:

I, (please print)_____________________________, the parent/legal guardian of

child(ren) (please print) _________________________________________________, understand that every reasonable effort will be made to inform me of any emergency situation immediately, and if I am not available, I authorize and consent to, and elect not to be informed in advance of, medical, surgical, and hospital care, treatment, or procedures to be performed for my child(ren) by a licensed physician or hospital, when, in the sole discretion of the attending physician, such care, treatment, and procedures are immediately necessary or advisable in the interest of my child(ren)’s health and well-being. I understand that I am responsible for payment of any medical bills incurred for my child.

Another person to contact in emergency:

Name________________________________________ Tel. ___________________

Address ______________________________________________________________

City_________________________________________ Zip ____________________

Relationship of contact person to child: _____________________________________

Signature of parent/legal guardian _________________________________________

Relationship to child(ren) ________________________________________________

Child’s physician______________________________Telephone__________________

Health coverage__________________________________________________________