Wisconsin Playground Warriors

PARENTAL CONSENT FORM

To Whom It May Concern:

 

I, __________________, authorize complete medical treatment for my child, ____________________, by a licensed physician in the event of a medical emergency. If the attending physician feels that delayed care may endanger my child's life, cause disfigurement, physical impairment, or undue discomfort, I grant this authority if a reasonable, yet unsuccessful, effort has been made to reach me.

Minor --____________________ Birthdate --________________

Relationship --_______________ PGC Team--_______________

 

Parent/Guardian ___________________

Address__________________________

_________________________________

Phone Number ____________________

 

Insurance Information:

_____________________ _____________
(parent/guardian signature) (today's date)