Parental Permission and Medical Consent (Canada)

This Parental Permission and Medical Consent form is designed for use in Canada. This legal form is available for immediate download.

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This Parental Permission and Medical Consent form allows a parent to give consent for a child to participate in an activity which is defined within the form. Having this form on hand allows organisers of an activity to deal with any type of emergency involving a child when a parent may not be readily available. A parent can also revoke this document at any time.

This lawyer-prepared packet contains:
  1. Instructions and Checklist
  2. General Information
  3. Parental Permission and Medical Consent form for use in Canada
Law Compliance: This form can be used in the following provinces: Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Northwest Territories, Nova Scotia, Nunavut, Ontario, Prince Edward Island, Saskatchewan and Yukon
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
 
 
Parental Permission and Medical Consent
(Canada)

 

 
 
RE:
Name: _________________________________ born on _____________________________
Social Insurance Number: ______________________________________________________
Address:  ___________________________________________________________________
 
The undersigned(s) being the lawful parent(s) and/or guardian(s) of the above child (the "Child"), hereby consents to the participation by the Child in ___________________________ (describe activity) conducted by __________________________________________________  (Name of “Organiser") and to the participation of the Child in all events relating to the activity on _______________ through _______________.
 
The undersigned hereby further authorise(s) any of the staff, employees, agents and representatives of Organiser to provide for, approve and authorise any health care at any hospital, emergency room, doctors office or other institution; employ any physicians, dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose the contents of any medical records; execute any consent form required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care to the child. Health care shall include but not be limited to the administration of anaesthesia, X-ray examination, performance of operations, diagnostic and other procedures.
 
If there is no medical emergency, the guardian will first use reasonable efforts to contact the parent(s) and/or guardian(s) before administering or authorizing any treatment.
 
Notwithstanding other provisions in this Consent Form, Organiser shall not have the authority to withhold or withdraw life-sustaining procedures for the Child.
 
This Consent Form may be revoked at any time before the expiration date with written notice to Organiser.  
 
Signed on ________________ (date), at __________________ (city),  _______________ (state).
 
________________________________
Signature of Parent
 
________________________________
Signature of Parent
 
Child Care Information and Instructions
 
Child's Name:
Child's Nickname:
Child's Age:
 
Parent(s) and Other Contacts
 
Mothers Name:
Fathers Name:
Address of Parent(s):
Home#
Work#
 
Second Contact Name:
Relationship:
Phone Number:
 
Third Contact Name:
Relationship:
Phone Number:
  
 
Medical/Health/Insurance Care Information
 
Childs Doctor Name:
Address:
Office Telephone:
After Hours Number:
 
Health Insurance Company:
Group or Policy Number:
Telephone Number:
 
Medications:  
Allergies:  
Immunisations:
Special Conditions:
 
 
 
 
 
Schedule & Instructions
 
Meals: __________________________
Snacks: _________________________
Naps:  __________________________
Bedtime:  _______________________
Other:  _________________________
 
Rules and Habits
 
 
 
 
 
 
 
Number of Pages6
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#33987
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
 
 
Parental Permission and Medical Consent
(Canada)

 

 
 
RE:
Name: _________________________________ born on _____________________________
Social Insurance Number: ______________________________________________________
Address:  ___________________________________________________________________
 
The undersigned(s) being the lawful parent(s) and/or guardian(s) of the above child (the "Child"), hereby consents to the participation by the Child in ___________________________ (describe activity) conducted by __________________________________________________  (Name of “Organiser") and to the participation of the Child in all events relating to the activity on _______________ through _______________.
 
The undersigned hereby further authorise(s) any of the staff, employees, agents and representatives of Organiser to provide for, approve and authorise any health care at any hospital, emergency room, doctors office or other institution; employ any physicians, dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose the contents of any medical records; execute any consent form required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care to the child. Health care shall include but not be limited to the administration of anaesthesia, X-ray examination, performance of operations, diagnostic and other procedures.
 
If there is no medical emergency, the guardian will first use reasonable efforts to contact the parent(s) and/or guardian(s) before administering or authorizing any treatment.
 
Notwithstanding other provisions in this Consent Form, Organiser shall not have the authority to withhold or withdraw life-sustaining procedures for the Child.
 
This Consent Form may be revoked at any time before the expiration date with written notice to Organiser.  
 
Signed on ________________ (date), at __________________ (city),  _______________ (state).
 
________________________________
Signature of Parent
 
________________________________
Signature of Parent
 
Child Care Information and Instructions
 
Child's Name:
Child's Nickname:
Child's Age:
 
Parent(s) and Other Contacts
 
Mothers Name:
Fathers Name:
Address of Parent(s):
Home#
Work#
 
Second Contact Name:
Relationship:
Phone Number:
 
Third Contact Name:
Relationship:
Phone Number:
  
 
Medical/Health/Insurance Care Information
 
Childs Doctor Name:
Address:
Office Telephone:
After Hours Number:
 
Health Insurance Company:
Group or Policy Number:
Telephone Number:
 
Medications:  
Allergies:  
Immunisations:
Special Conditions:
 
 
 
 
 
Schedule & Instructions
 
Meals: __________________________
Snacks: _________________________
Naps:  __________________________
Bedtime:  _______________________
Other:  _________________________
 
Rules and Habits
 
 
 
 
 
 
 

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