Maranatha Seventh-day Adventist Christian School
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Consent to Treatment Form- Field Trip/Off Campus
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PERMISSION/CONSENT TO TREATMENT
AND HEALTH INSURANCE INFORMATION
(Off Campus – take on trip)
 
Wisconsin Conference of Seventh-day Adventists                         ____________________________________
                                                                                                                                                School Name
 
We/I, the undersigned parents or guardian of __________________________________ a minor, do hereby give
                                                                                                Child’s name
our/my permission/consent for the above named child to participate in the following school sponsored activity:
 
_______________________________________ to be held at _______________________________________,
 
on the dates of ______________________ between the hours of _____________ and _______________.
 
We/I are/am aware that by our/my child participating in this activity there is the possibility there may occur a need for emergency medical treatment as a result of accident or sickness.
 
In the event emergency medical treatment becomes necessary for my child, we/I grant to ________________
                                                                                                                                                      Teacher or Director
or their assistants authority to obtain such emergency medical assistance.
 
____We/I further grant to the medical care provider the authority and permission to administer emergency medical treatment.
____We/I consent to my child being transported to/from the above stated activity premises by private car, church/school owned bus or other means, for the purpose of the above state activity.
 
                                    Drivers: ______________________              ______________________
 
____We/I understand the school will supply no transportation. Each child is responsible for their own transportation to and from the above stated activity.
 
This permission/consent shall remain in continuous effect until revoked in writing and delivered to the above named teacher/director or to the person entrusted with the custody of said minor.
 
The above named minor is ___, is not ___ covered by health insurance.
 
Present Health Insurance Company _______________________ Policy Number ________________________
 
________________________________________                            ____________________________________
Signature of Father                                                                             Date
 
________________________________________                            ____________________________________
Signature of Mother                                                                            Date
 
________________________________________                            ____________________________________
Signature of Guardian                                                                                    Date
 
Parents Names: _______________________________________
 
Address: _____________________________________________
 
Phone – Father - home (      )____________ work (     )______________   Cell (     )____________
 
Phone – Mother - home (      )____________ work (     )______________   Cell (     )____________
 
C:\Documents and Settings\Owner\My Documents\Red Book\Consent to treat off campus.doc