WINTER RETREAT FEB 19-21
What To BRING.
Bible, Sleeping Bag, Pillow, Toiletries, Towel, Warm Jacket, Warm clothes,
Parent Permission Forms, Appropriate sleeping attire, Snow Play attire
Student
Ministries Retreat
Twin Peaks, California - February 19-21, 2009
Cost: $130
(Please Print or Type Legibly)
Last Name:
__________________________________________
First Name: __________________________________________
Middle Initial: ________
Gender: (Circle One) Male Female
Birth-date: ________________ Grade (last year):
_______________
Address:________________________________________________________________
City: _________________________ State: Zip: __________________
Home Phone: ( ) _________ Cell Phone: :( )
_______________
E-Mail Address:
__________________ @________________
Home
Church: Huntington Beach Community Church of the Nazarene
Roommate
Preference (not guaranteed): _________________________
Parent / Guardian: (signature) _____________________________________________
First Name: _________________ Last Name: _________________
Address (if different from above):
______________________________________________
City: ___________________ State: __________ Zip:
________________________
Home Phone: ( ) ____________
Work Phone:
:( ) _______________ Cell Number: ( ) _____________
In an Emergency,
if we can't contact the parent or guardian, who should we contact?
First Name: ______________ Last Name: ________________
Home Phone: ( ) ______________ Work Phone: :( ) ______________
Cell Number: ( ) _________________
No Teen will be allowed to attend Camp without this registration Parental
Authority to Consent to Treatment & Medical Forms are on file.
Parental Authority to consent to treatment of minor
___________________________________
______________________________________
Herein
"Parent/Guardian"
Herein "Minor"
Anaheim District Church of the Nazarene Anaheim District Teen
Winter Camp Staff
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, 2011
unless sooner revoked in writing delivered to said Agent.
Parent/Guardian's Signature
_____________________________________________
Dated: _________2010
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.
MEDICAL INFORMATION FORM
Student Name:
____________________________________________________________
Insurance Company:
____________________________________________________________
Policy No:
____________________________________________________________
Claims Office:
Address: _____________________________________________________________
City: _______________________ State:_____________ Zip:
____________
Phone Number: ( ) __________________
Employer Name:
Address: _____________________________________________________________
City: _______________________ State: ___________________ Zip:
_____________
Phone Number: ( ) ___________________
Where Parent can be
reached:
Address: _____________________________________________________________
City: ____________________ State: ___________________ Zip:
__________________
Home Phone: ( ) ________________ Work Phone: :( )
________________
Cell Number: ( ) _______________________
Special Medical conditions of minor, such as diabetes, or allergic reactions:
Medications currently using: