St. Mary’s Episcopal Church Parental Consent Form

Event Name _St. Mary’s Episcopal Church ______________________________
Effective from___________________through      ___________________________

Name___________________________________Birthdate _________  M     F
Street ____________________________________Phone________________
City ______________________ State________ ZIP_________

Grade_____
Parish & Location:  St. Mary’s Episcopal Church, Arlington, VA
Daytime Phone: _____________Mother______________ Father_____________
Additional Phone Numbers ___________________________________________
Other Contact (name & number)_______________________________________
Group Contact: Church Phone: 703-527-6800
Insurance Co.______________________________ Policy #_________________
Ins. Co. Phone Number: ______________
Health Concerns (medication, allergies, surgeries, diet) :

• I hereby give permission to this youth to attend and participate in activities sponsored by St. Mary’s Episcopal Church Youth Group, and 

• I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, or hospital care, to be rendered to the minor under the general or specific supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital. I will be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the above-named youth pursuant to this authorization, and

• I hereby give permission for this youth to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in this event.


Participant  __________________________ Date ___________________

(If 18 or older, only "Participant" should sign.  If under 18, continue below.)

Parent/Legal Guardian _______________________ Date _________________