ATTENDEE INFORMATION:
Name (First, Last):
Address:
Home Phone: (____) - Cell Phone: (____) - _
E-mail: @
Sex (Male, Female) :
Grade: (Jr. High, Sr. High, Adult)
Church:
Delegate: (Yes or No)
Check with your Youth Worker to see if you are a delegate
In an Emergency, we should contact…?
First Name:_____________________ Last Name:____________________________________
Relationship: _________________________________________________________________
Address: _____________________________________________________________________
City: _________________ State: _______ Zip: __________________
Home Phone: ( ) ___Work Phone: ( ) __ ___Cell Number: ( ) _______
This sheet is to be filled out by ALL attendees & returned to the YOUTH LEADER
Be sure to fill out both sides of this form!
No Teen will be allowed to attend without this on file!
Parental Authority to consent to treatment of minor
___________________________________ ______________________________________
Herein “Parent/Guardian” Herein “Minor”
Anaheim District Church of the Nazarene Anaheim District and Anaheim District NYI
Herein “Organization” Herein “Agent”
The above-named Parent/Guardian of the Minor has entrusted the Minor into the care of the Agent, and adult, and a duly authorized representative of the Organization, while the Minor participates in an activity sponsored by the Organization, and for the welfare of the Minor.
The Parent/Guardian does hereby authorize the 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/or surgeon licensed under the provisions of the California Medical Practice Act or of the laws of the state or country in which 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 a dentist licensed under the California Dental Practice Act or the laws of the State or Country in which the dental care is being sought.
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 25.8 of the Civil Code of California, and similar provisions of the laws of the State or Country in which the medical or dental care is being sought.
The Parent/Guardian hereby authorizes any hospital which 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 similar provisions of the laws of the State or Country in which the medical or dental care is being provided.
The Parent/Guardian hereby agrees to fully pay all costs of medical or dental care incurred for the Minor by the Agent, or the Organization, under this authorization.
These Authorizations shall
remain effective until January 1, 2010
unless sooner revoked in writing delivered to said Agent.
Dated: Parent/Guardian’s Signature ___________________________
Civil Code of California, Section 25.8
Either parent if both parents have legal custody, or the parent or person having the legal custody or the legal guardian, or a minor may authorize in writing any adult person into whose care the minor has been entrusted to consent to any X-ray examination, 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 examination, 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 & 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, the person having legal custody of the child, or the care giver of the child who is a relative of the child and who may authorize medical care and dental care under Section 6550 of the family code.