Grace Church of Mentor Extreme Games

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Child's Full Name
Grade Completed
Gender
Address:
City:
Home Phone:
Email:
Parent/Guardian:
Parent Cell Phone:

Please Complete One of the Following:

Consent for Medical Treatment: In the event that reasonable attempts to contact a parent or guardian have been made without success, I give my consent for the administration of treatment deemed necessary by a licensed physician or dentist and the transfer of the child to any reasonably accessible hospital. By clicking "Submit" at the end of this form, I verify that I am the Parent/Guardian of above mentioned child and I am over 18 years of age.

Name:

Refusal of Consent for Medical Treatment: I do not give my consent for emergency medical treatment of my child. In the event of an emergency I wish Grace Church to take no action. By clicking "Submit" at the end of this form, I verify that I am the Parent/Guardian of above mentioned child and I am over 18 years of age.

Name:

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