Consent Form - Blank
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Consent and Authorization Form West Jordan Utah Jordan Oaks Stake 5th Ward Participant's Name
Cell Phone
Address
Date of Birth
Home Phone
Parent's Cell phones
Consent and Authorization I give my consent for the above-named person to participate in the activity programs of the West Jordan Utah, Jordan Oaks Stake 5th Ward, including (describe activity):
Parent's Authorization (required for those under 18 years of age) This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me and the physician. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the adult leader in charge to hospitalize, secure proper anesthesia, or to order injection or surgery for my child. Signature of Parent or Guardian
Date
Medical Information (to be used if necessary): Do you have or require any of the following (circle): Yes Yes Yes Yes Yes Yes
No No No No No No
Special Diet Allergies Physical condition that would limit activity Medication chronic or recurring illness have you had surgery or a serious illness in the past year
If the answer is “yes” to any of the above, give a full explanation of each on the back.
Cell Phone
Address
Date of Birth
Home Phone
Parent's Cell phones
Consent and Authorization I give my consent for the above-named person to participate in the activity programs of the West Jordan Utah, Jordan Oaks Stake 5th Ward, including (describe activity):
Parent's Authorization (required for those under 18 years of age) This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me and the physician. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the adult leader in charge to hospitalize, secure proper anesthesia, or to order injection or surgery for my child. Signature of Parent or Guardian
Date
Medical Information (to be used if necessary): Do you have or require any of the following (circle): Yes Yes Yes Yes Yes Yes
No No No No No No
Special Diet Allergies Physical condition that would limit activity Medication chronic or recurring illness have you had surgery or a serious illness in the past year
If the answer is “yes” to any of the above, give a full explanation of each on the back.
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