cornerstone new logo_edited-1.jpg — 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

First Name

Last Name

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name

First Name

Last Name

Child's Birthdate

YYYY

Allergies

Date of Last Tetanus

YYYY

Additional Information

Special Medications, Blood Type, or any other Pertinent Information you want us to have

Child's Physician

First Name

Last Name

Physician's Phone Number

(###)

###

####

Electronic Signature