-- PARENTAL CONSENT FORM --
TO BE COMPLETED BY PARENT OR GUARDIAN:
________________________ has my/our permission to attend the Anglican Youth Camp. In the event of an emergency my authorization for emergency treatment is provided below.
I (We) the undersigned parent(s) or guardian(s) of _______________________, a minor, do hereby authorize and consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment rendered under the general or special supervision of any member of the medical staff and emergency staff licensed under the provisions of the Medicine Practice Act, or a dentist licensed under the provisions of the Dental Practice Act, or the staff of any acute general hospital holding a current license from the State of California, Department of Public Health, to operate a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power to render care which the aforementioned physician, in the exercise of his (her) best judgment, may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.
List any restrictions:__________________________________________________________
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CALIFORNIA STATE LAW PROHIBITS THE SALE OF TOBACCO PRODUCTS TO MINORS, IN ADDITION THE CAMP IS LOCATED IN A WILDERNESS AREA WHERE FIRE DANGER MAY BE EXTREME. THEREFORE SMOKING WILL BE PROHIBITED AT THE CAMP.
SIGNATURE OF PARENT(S) OR GUARDIAN(S):
________________________________________________________ DATE_____________
________________________________________________________ DATE_____________
Please list any allergies, medications being taken, medical problems, special diet, or other pertinent information:
__________________________________________________________________________
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In the event that your child must return home before the week is over, or in case of a medical emergency, please provide telephone / pager / cellphone numbers where you can be reached during the day and evenings:
Daytime Phone (_____) _________________ Evening Phone (_____)_______________
Cell phone (____) _____________________ Pager (____) ______________________
Alternate Emergency Phone (____) ________ Whose number is this? _______________