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Authorization and Consent to Medical and Dental Care

This form must be completed and signed by the parent/legal guardian of all Participants under age 21.


I, the undersigned parent and/or legal guardian of (please list all children’s names below) do hereby authorize Midwestern Baptist Theological Seminary (“MBTS”), their employees, or other adults designated by MBTS  to: (i) consent to medical, surgical, and/or dental care for my child; (ii) consent to any diagnostic tests, medical, surgical, and/or dental procedures or treatments as may be reasonably necessary as determined by a physician, surgeon, dentist, or other healthcare provider providing care for my child; and (iii) on my behalf, to: (a) employ physicians, surgeons, dentists, nurses, and other healthcare personnel as may be necessary for my child’s care; (b) admit my child to any hospital, clinic, emergency room, laboratory, or other healthcare or diagnostic facility for examination, treatment, surgery, or care; (c) release any known and/or provided relevant medical information about my child, including but not limited to the information contained in the Emergency Medical Information Form given to MBTS as required for participation in the Kids For the Church childcare program; and (d) sign all necessary consents and authorizations.  I understand that this authorization is given in advance of the occurrence of any condition or situation which would necessitate any such medical, surgical, or dental care being required, but is given to provide authority to obtain such care for my child should such care be required.  I fully understand the consequences of the foregoing statements and sign this Authorization and Consent to Medical and Dental Care knowingly, freely, and willingly.
This authorization shall continue for the full period of my child’s participation in the Kids For the Church childcare program.