Digital Signature
The above-named student has my permission to attend -THE SELECTED EVENT-
It is understood that I will not hold the Montana Conference, the church, schools, or their personnel responsible in case of accident or injury beyond that coverage provided by the student accident insurance program of the Montana Conference.
We, the undersigned parents or guardian of the above-named student, a minor, do hereby consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be rendered to said minor under the general or special instructions of the named medical clinic or my child’s doctor., or any physician the school or organization may call, whether such diagnosis or treatment is rendered at the office of said physician or at a licensed hospital. It is understood that reasonable effort will be made to contact the doctor listed above before any other physician is called by the school or other organization.
It is further understood that this consent is given in advance of any specific diagnosis or treatment which might be required and is given to authorize the Montana Conference of Seventh-day Adventists or the physician to exercise the best judgment as to the requirements of such diagnosis or treatment.
This consent shall remain in continuous effect until revoked in writing and delivered to the physician named above or to the school or organization entrusted with the custody of said minor.
We hereby authorize any hospital, physician, or other person who has attended or examined the minor to furnish the General Conference Insurance Service, or its representative, any and all information with respect to any illness, medical history, consultation, prescriptions, or treatment, and copies of all hospital medical records. A photo copy of this authorization shall be considered as effective and valid as the original.
