Children's Ministry Consent to Treatment
I (Parent or Guardian) hereby authorize the youth sponsor representing Grace Central Coast of San Luis Obispo, California, as agents 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 general or special supervision of any physician and/or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at office or said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care required but is given to provide authority and power on the part of aforesaid agents to give specific consent to any and all such diagnosis, treatment and hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable.

This authorization is given pursuant to the provision of Section 25-8 of the Civil Code of California. This authorization is to be effective until revoked in writing by said agent. It is understood that parents or legal guardians are responsible for all costs not covered by church youth group insurance.

Child's Name: *
Last, First
Your answer
Child's Birth Date: *
Your answer
Parents or Legal Guardian Names: *
Last, First (Both names, if applicable)
Your answer
Address of Parent or Legal Guardian *
Address, City, State, Zip
Your answer
Home Phone Number *
Your answer
Mobile Phone Number *
If this does not apply please fill in N/A
Your answer
Relative's Name and Phone Number: *
To be contacted if Parent/Guardians cannot be reached
Your answer
Parent's Email Address: *
Your answer
Specific Instructions to the Nurse or Doctor: *
Include special medication, medical disorders and instructions/dosages
Your answer
Allergies: *
Your answer
Permission for IBP or Tylenol *
If child had headache, fever, etc...
Date of Last Tetanus Shot: *
Your answer
Family Physician or Medical Group: *
Your answer
Insurance Company and Policy Number *
Your answer
Parent or Legal Guardian: *
Required
Consent to Treat: *
By checking this box I give permission to GraceSLO staff or volunteers to authorize medical treatment for my child if I am unable to be reached.
Required
Electronic Signature *
First and Last Name
Your answer
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