Authorization to Treat a Minor
By signing below I understand that: 1.I (We) the undersigned parents, parents, or legal guardian of the individual listed below, a minor, do hereby authorize consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable, rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act or a Dentist licensed under the provisions of the Dentist Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Health. It is understood that this authorization, given in advance of any specific diagnosis, treatment, or hospital care being required, is given to provide authority and power to render care that the aforementioned physician in the exercise of his 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(s) 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.
1. URGENT NOTICE: We are forbidden, by law, to administer ANY medicine without the written consent of a parent. Any medication to be given to students must be in the original prescription container, have the student's name and instructions clearly marked by the pharmacist or doctor, and be given to the school office or school nurse.
2. I understand that this consent shall remain effective as long as the student is enrolled in school.
3. I do hereby authorize consent to treat my child(ren).
4. I do understand that effort will be made to contact me (or my spouse) prior to rendering treatment, but that any of the above-listed treatments will not be withheld if I am not able to be reached.
5. I hereby release C. & E. Merdinian Armenian Evangelical School and the member of the staff who administers the medication from all responsibility.
By signing here, you agree that you are the parent or legal guardian of the above-named camper.
I understand that the above-named camper will only be released to the names listed above.
I certify that my child has my permission to attend summer camp and participate in all activities. I authorize Merdinian School to use my camper's picture and video in any promotional material (web, print, or media).
