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CONSENT TO TREAT A MINOR

 
 

As the parent or legal guardian, I do hereby consent to any medical care as determined by a physician to be necessary for the welfare of my child while said child is under the care of Cornerstone Community Church and I am not reasonably available by telephone to give consent.

 
Parent or Legal Guardian *
Parent or Legal Guardian
Phone Number *
Phone Number
Address *
Address
Child's Name *
Child's Name
Child's Birthdate *
Child's Birthdate
Date of Last Tetanus
Date of Last Tetanus
Special Medications, Blood Type, or any other Pertinent Information you want us to have
Child's Physician
Child's Physician
Physician's Phone Number
Physician's Phone Number