2009 Missouri Envirothon

Parental Consent

Turn In At Registration

All information must be completed in full.

Type or print clearly.

Dear Parent / Guardian,

The law requires that parental permission be obtained for medical procedures performed on minors (under 18 years of age). The following consent form should be signed by a parent and/or legal guardian so that such procedures can be promptly carried out. We will make a genuine attempt to notify you in case of a serious emergency.

I, the undersigned parent / guardian of ________________________________, hereby give permission to physicians and attendant staff to perform such diagnostic, therapeutic, and operative procedures for him/her as they deem necessary.

Name of Parent / Guardian: _________________________________________

Please print or type name

Address: ________________________________________________________

Home Telephone: _________________ Work Telephone: _________________

Relationship to Student: ____________________________________________

                                                (parent, foster parent, guardian, etc.)

Name of Advisor accompanying student: _______________________________