Volunteer Activity Medical Consent for Minor

Minor Information

Full Name of Minor

Date of Birth

Age

Parent/Legal Guardian Information

Name of Parent/Legal Guardian Phone Number Email Address

Medical Information

Physician’s Name Physician’s Phone Number List any allergies or medical conditions Current medications Health Insurance Provider Policy Number

Consent

I, the undersigned, am the parent/legal guardian of the above-named minor and hereby authorize medical treatment for my child in case of illness or emergency while participating in the volunteer activity.

Signature of Parent/Guardian

Date