(cache) AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR

AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR

This should be filled out by parents of employees who will not be 18 years old by June 1

(I) (We), the undersigned parent(s)/guardian(s) of __________________________, a minor, do hereby

authorize University of California, Berkeley Health Services or attending medical personnel as agent(s)

for the undersigned to consent to any X-ray examinations, anesthetic, medical or surgical diagnosis or

treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or

special supervision of, any physician and/or surgeon licensed under the provisions of the Medical

Practices Act, California Business and Professions Code §2000 et. seq.; or any X-ray examination,

anesthetic, dental or surgical diagnosis or treatment, or hospital care which is deemed advisable by, and

is to be rendered under the general or special supervision of, any dentist licensed under the provisions of

the Dental Practices Act, California Business and Professions Code §1600 et. seq.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital

care to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any

and all such diagnosis, treatment or hospital care which aforementioned physician or dentist, in the

exercise of his/her best judgment, may deem advisable. This authorization is given pursuant to the

provisions of California Family Code §6910.

(I) (We) hereby authorize any hospital, which has provided treatment to the above-named minor pursuant

to the provisions of California Family Code §6910, to surrender physical custody of such minor to (my)

(our) above-named agent(s) upon the completion of treatment. This authorization is given pursuant to

California Health and Safety Code §1283

These authorizations shall remain effective until revoked in writing delivered to said agent(s).

Signature of Parent/Guardian of Minor

Date

CAL YOUTH PARTICIPANT AGREEMENT

This health history is correct so far as I know, and my son/daughter has permission to engage in all

prescribed camp activities, except as noted by me. My son/daughter is in good health.

I understand that I am required to have accidental medical coverage for the child listed on this application,

and I verify that the information provided on this form is accurate and true. I understand and agree that if

I do not have accidental medical coverage for the child listed on this application, I will be financially

responsible for all charges and fees incurred in the rendering of said treatment

I understand that at the discretion of camp/program supervisor and/or staff my child may be dismissed

from the camp/program, for inappropriate behavior.

I understand that at the conclusion of the scheduled camp/program time, Cal Youth and Outdoor

Programs are no longer responsible for my child.

I give permission to use, reprint, and produce any photographs or videos taken of me or my child and

written materials supplied by me or my child in the form of evaluations during the Cal Youth Program. I

understand that such material will be used for university marketing purposes only.

Signature of Parent/Guardian of Minor

Date

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