Child Consent Sponsorship Form - PDF by uqs23775


Child Consent Sponsorship Form document sample

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									    Child Sponsorship Form – Green Lake Bahá'í Conference
               To be filled out by the parent/guardian of individuals being sponsored

Parent / Guardian Authorization
I, the undersigned parent/guardian of the following individual(s), do hereby authorize listed sponsor(s) as
agent(s) of the undersigned, including authorization to consent to any x-ray examination, anesthetic,
medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is
rendered under the general or special supervision of any physician and surgeon licensed under the
provisions of the Medicine Practice Act on the medical staff of a licensed hospital, whether such diagnosis
or treatment is rendered at the office of said physician or at said hospital. As the parent/guardian of a
minor under the age of 18, I understand that this authorization enables the Green Lake Baha’i
Conference Planning Committee to arrange medical care for my dependent minor in the event I am
unavailable. This authorization shall remain in effect during the August Green Lake Bahá’í Conference.
Printed Name of Parent / Guardian: _____________________________________________________
Signed : ______________________________________________ Date : _____________________
Sponsor(s) Name(s)
Each child or youth under age 18 who attends the school without a parent or legal guardian must be
accompanied by a sponsor who will be responsible for the child’s conduct and well being. I understand
and agree to accept these responsibities for listed children and youth.

Sponsor Name: _________________________ 2nd Sponsor Name: ___________________________

Parent/Guardian Contact Information
Parent/Guardian Name: ______________________________________________________________
Work Phone: ______________         Home Phone: ____________
Emergency Contact Name: _______________________
Work Phone : _____________         Home Phone: _____________

Child (Children) or Youth Being Sponsored
1. Name: ___________________________ Birthdate: ________ Allergies or special needs:

2. Name: ___________________________ Birthdate: ________ Allergies or special needs:

3. Name: ___________________________ Birthdate: ________ Allergies or special needs:

Physician and Insurance Information
Physician’s Name: ___________________________________________________________
Physician’s Address: __________________________________________________________
Physician’s Phone: ___________________________________________________________
Insurance Carrier: ____________________________________________________________
Group Number: _____________________ Plan Number: ____________________________
Policy Number: ______________________ Member ID Number: _______________________

Send signed forms with registration materials to Green Lake Registrar at 955 E Gorham St, Madison, WI
53703 or fax (845-875-0528) or bring to the conference. Failure to provide will result in denial of rights of
sponsored children to attend the conference. Questions? Call 608-232-9079.

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