Grace CHURCH

PARENT'S OR GUARDIAN’S AUTHORIZATION TO CONSENT TO

MEDICAL OR DENTAL TREATMENT OF MINOR 

PLEASE USE INK AND PRINT EXCEPT FOR SIGNATURE LINES 

The undersigned _______________________________________ ("Parent") who is a parent or legal guardian of _______________________________________ ("Minor") does hereby authorize Grace Church ("Agent"), as agent for the undersigned, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician and surgeon licensed under the provisions of the California Medical Practice Act or of the laws of the State or country in which the medical care is being sought and on the medical staff of any hospital; or to consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment to be rendered to the Minor by any dentist licensed under the California Dental Practice Act or the laws of the State or Country in which the dental care is being sought, when the need for such treatment is immediate and/or when efforts to contact me are unsuccessful. 

It is understood that this authorization is given in advance of any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care being required but is given to provide authority and power on the part of the Agent to give specific consent to any and all such examination, anesthetic, diagnosis, treatment, or hospital care which the aforementioned surgeon, physician and/or dentist, in the exercise of his/her best judgment, may deem advisable. 

This authorization is given pursuant to the provisions of Section 2.5.8 of the Civil Code of California, and/or similar applicable provisions of the laws of the State or Country in which the medical or dental care is being sought. 

The Parent or Guardian hereby authorizes any hospital that has provided treatment to the Minor to surrender physical custody of the Minor to the Agent upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety code of California and/or similar provisions of the laws of the State or Country in which the medical or dental care is being provided. 

The Parent or Guardian hereby agrees to fully pay all costs of medical or dental care incurred for the Minor by the Agent under this authorization. 

These authorizations shall remain effective until _______________________, unless sooner revoked in writing delivered to Agent.

Dated: Name of Father, Mother, and/or Legal Guardian:______________________

Parent/Guardian Signature:  

Address:  

Home Phone: Work Phone:  

Cell Phone:______________________________ 
 

INSURANCE INFORMATION 
 

Insurance Company:  

Claim Office Address:  

Claim Office Telephone Number:  

Policy No.:  

Employer Name:  

Address:  

Phone:  

Special Medical Conditions of Minor, such as Diabetes, Allergic Reactions, Current Medications: 
 
 
 
 

Doctor's Name:  Phone:  
 

CIVIL CODE OF CALIFORNIA, SECTION 25.8

Either parent if both have legal custody, or the parent or person having legal custody or the legal guardian, of a minor may authorize in writing any adult person into whose care the minor has been entrusted to consent to any x-ray examination on, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act or to consent to an x-ray exam, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act. 

HEALTH AND SAFETY CODE, SECTION 1283(a)

No health facility shall surrender the physical custody of a minor under 16 years of age to any person unless such surrender is authorized in writing by the child's parent or the person who has legal custody of the child.

THIS FORM MUST BE FILLED OUT COMPLETELY OR STUDENT WILL NOT BE ALLOWED TO ATTEND ACTIVITY 

This form must be on file with Grace in order to participate on overnight activities.  Once on file, it is valid for all future activities. 
 

ASSUMPTION OF RISK AND RELEASE OF LIABILITY AGREEMENT WITH GRACE CHURCH and Authorization to Treat a Minor

In consideration for being allowed to participate and/or have a minor child participate in recreational activities defined as guided Grace Church activities offered and/or provided by GRACE CHURCH, a California non-profit corporation, (hereafter collectively referred to as GRACE CHURCH), I hereby acknowledge and agree as follows:  

1. Assumption of Risks. Participation in GRACE CHURCH Activities is voluntary. I understand that GRACE CHURCH Activities consist of dangerous sports which can result in bodily injury, death, and/or damage to property for many reasons, including but not limited to rafting, rock climbing, snow boarding, snow skiing, water skiing, wave running, backpacking, driving, or  accidents involving third parties known and unknown to GRACE CHURCH; equipment failure, malfunction, or misuse; drowning; falls:  ill health, including illnesses and injuries brought about by participating in activities; weather conditions such as storms and lightning; venomous insects and snakes; wild animals; the training, acts, omissions, recommendations or advice given by GRACE CHURCH concerning rafting, rock climbing, snow boarding, snow skiing, water skiing, wave running, backpacking and related activities such as transportation to and from the site, and camping; and first-aid, emergency treatment or other service rendered to me or others. I understand and acknowledge that the above list of reasons is not complete or exhaustive.

I accept and hereby assume all risks of injury, death, illness or disease, or other damage to myself,  to others, or to my property which arise from participation in the referenced activities.

2. Release. I hereby voluntarily release, and forever discharge GRACE CHURCH and its subcontractors, employees, agents, and all other persons or entities, including other participants, (hereafter collectively "the released parties”) from all liability, claims, demands, actions or causes of action for bodily injury, death, illness, disease or damage to myself, to any participating minor child of mine, or to my property which are related to, arise out of, or are in any way connected with participation in the above referenced activities, including but not limited to those arising from any negligent or reckless acts or omissions or breach of contract of the released parties, or hidden defects in the equipment used. This release is intended to be as broad and inclusive as is permitted by California law, and shall be construed and interpreted under California law. If any portion, clause or subclause is held invalid, I agree that the balance shall continue in full force and effect.

3. If GRACE CHURCH or anyone on its behalf is required to incur attorney's fees and costs to enforce this agreement against me, I agree to indemnify and hold them harmless from all such fees and costs.

4. I certify that I am fully capable of participating in these activities. I agree to follow all rules and instructions of the released parties while participating in the above activities.

5. I acknowledge and agree that by signing this document, I am giving up the right to sue the released parties for any damages I suffer or any minor child of mine suffers while participating in the above referenced activities, even if the released parties negligently cause said damages. I have read and understand this entire document. It is effective  and binding upon me, my heirs, assigns, personal representatives, estate, and any minor child of mine who is participating in these activities.

6. I acknowledge that I am not relying on any oral, written, or visual representations or statements made by the released parties, including those made in released parties' brochures or other promotional material. I agree that GRACE CHURCH may use photos or video records of this trip for its promotional and/or commercial purposes.

7.  Further, I (we) the undersigned parent, parents, or legal guardian of minor participant, do hereby authorize any leaders from GRACE Church to authorize and consent any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the Department of Public Health.  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 best judgment, may to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. 

Participants/Students Name: Phone: 

Birth Date: Birth City and Country:  Country of Citizenship: 

Name of Father, Mother, and/or Legal Guardian:  

Telephones Where Parents/Guardians May be Reached:    

      Father - Home  Business

Students Graduating Year:     

      Mother - Home  Business

Family Physician: _________________________________________________Phone:  

Address:  

Last Tetanus Toxoid Booster: Allergies to Drugs or Goods:  

Any Special Medications or Pertinent Information:  

List Any Restrictions:  

Insurance Company: _________________________Policy #:________________Group #:  
 

Signature of Father, Mother, Legal Guardian on behalf of minor participant (Both Signatures Required), or Participant if over age 18 Date 

Address City State Zip 

This waiver of liability will remain effective through the duration of participation with GRACE Church unless revoked in writing by the undersigned and delivered to the aforesaid agent.

This form is to be completed and turned in to GRACE CHURCH 24600 La Plata, Laguna Niguel, CA 92677.  Phone (949)495-2987. 

****A PHOTOCOPY OF YOUR INSURANCE CARD****

      ****MUST BE GIVEN WHEN FORM IS HANDED IN ****