I, the undersigned parent or guardian of the above named participant, a minor, do hereby authorize the California Regional Training Institute, or its designated representative, agent(s) 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 rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. As the parent/guardian of a minor under the age of 18, I understand that this authorization enables representatives of the California Regional Training Institute to arrange medical care for my dependent minor in the event I am unavailable.

I understand that I am responsible for payment of any and all medical expenses incurred on behalf of my dependent minor. This authorization shall remain effective during the time when my child is attending the groups of the youth spiritual empowerment program.

I grant the California Regional Training Institute or its designated representative, permission to use my child’s name, likeness or image in any printed or electronic material for the purpose of documenting, reporting and promoting the programs of the Institute.  

Please write your full name below.

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En caso de enfermedad o heridas, yo, el padre o guardian, menor de edad,  por medio de la presente autorizo al personal del California Regional Training Institute para usar su juicio en obtener servicios médicos de emergencia, incluyendo rayos equis, examen, anestesia, diagnosis o tratamiento médico, quirúrgico o dental, o tratamiento y cuidados en el hospital si se considera necesario a mejor juicio del personal médico del hospital o lugar que proporciona servicios médicos o dentales. Como padre/guardián legal de un menor de 18 años, entiendo que esta autorización permite a los representantes del California Regional Training Institute para organizar la atención médica de mi dependiente menor de edad en el caso de que yo no esté disponible.

Entiendo que soy responsable por el pago de cualquier o todos los gastos médicos incurridos en nombre de mi menor dependiente. Esta autorización se mantendrá vigente cuando mi hijo asiste a los grupos de empoderamiento espiritual pre-juvenil.

Por favor escribe su nombre abajo.