Parental Authority To Consent To Treatment Of Minor And Release Of Liability Agreement Template

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PARENTAL AUTHORITY TO CONSENT TO TREATMENT
OF MINOR AND RELEASE OF LIABILITY AGREEMENT
(California Form)
First Baptist Church at La Crescenta
__________________________________
____________________________________
Herein “Parent” (“Parent” includes a Guardian)
Herein “Organization”
FBCLC Youth Group
__________________________________
____________________________________
Herein “Minor”
Herein “Agent”
The above named Parent of the Minor has entrusted the Minor into the care of the Agent, an adult and 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 does hereby authorize the Agent as agent for the undersigned to consent to any X-ray, 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 the laws of the State or Country in
which the 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 any 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, treatment of 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 6910 of the Family 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 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 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.
Furthermore, Parent voluntarily releases discharges, waives and relinquishes all claims that they may have against Agent or
Organization, its officers, employees and volunteers, for any and all claims, actions, or causes of action for personal injury, property damage
or death occurring to Minor arising out of Organization’s administration of or failure to administer medicine or medication to Minor, save and
except only those claims due to Organization’s gross negligence, fraud or willful injury to the person or property of Minor or violation of law,
whether willful or negligent.
These authorizations shall remain effective until June 30, 2014, unless sooner revoked in writing delivered to said Agent.
No oral representatives, statements, or inducements have been made by or between the parties to this Agreement with respect to
the subject matter of this Agreement apart from the matters set forth within this Agreement.
I HAVE CAREFULLY READ THIS CONSENT TO TREATMENT OF MINOR AND RELEASE OF LIABILITY
AGREEMENT BETWEEN PARENT AND ORGANIZATION, AND SIGN IT OF MY OWN FREE WILL.
____________________________
Dated
______________________________________
_______________________________________________
Parent’s Name
Parents Signature
Please fill out medical information on back page

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