Parental Consent Form
On October 7, 2018, 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. This will be done under the general or special supervision of any physician or dentist licensed under the provisions of the Medical Practice Act.
I shall be liable and agree to pay all costs and expenses incurred in connection with such medical and/or dental services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for my child to return home due to medical reasons or otherwise, I shall assume all transportation costs.
I also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by St. John Evangelical Lutheran Church, Wheaton, Illinois.
I hereby give permission for my above-named minor to attend and participate in activities sponsored by St. John Evangelical Lutheran Church, Wheaton, Illinois.
By checking this box, I verify that I am the parent or legal guardian of the above-named minor. I have read and agree to the preceding consent form.
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