Waivers & consent

Medical treatment authorization form template

Standalone medical consent for a trip, camp, or season: insurance, physician, allergies and medications, and a signed authorization to treat.

The form

Fields

15 questions

Participant name *Short text
Date of birth *Date
Program, trip, or team *Short text
Parent or guardian name *Short text
Parent or guardian phone *Phone
Alternate phonePhone
Health insurance provider *Short text
Insurance member IDShort textAs printed on the card.
Insurance card (front)File
Physician name and phoneShort text
AllergiesLong textWrite "None" if none.
Current medicationsLong textName, dose, and time. Write "None" if none.
Medical conditionsLong textAsthma, diabetes, seizures, and anything staff should be ready for.
Authorization to treat *Terms agreementIf I cannot be reached in an emergency, I authorize staff to seek medical care for the participant, and I authorize licensed medical providers to give the treatment they judge necessary, including hospital admission, anesthesia, and surgery. I agree to pay for that care, and I allow the health information on this form to be shared with the providers treating the participant.
Parent or guardian signature *Signature

Every field here is a standard TazForm field type, so the form loads in one click from the builder's “Start from a template” — then edit anything.

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