Form Fm S812 - Authorization For Medical Treatment

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AUTHORIZATION FOR MEDICAL TREATMENT
(Conformed as to California Law)
I, (NAME OF PARENT OR GUARDIAN OF MINOR), am the parent or legal guardian of (NAME OF MINOR)
(hereinafter "my child"), who was born on
,
.
My child is attending and participating in activities at (NAME OF ORGANIZATION) (hereinafter "this camp,"
"church," "school," etc.) located at:
in the City of
, County of
,
and State of
, beginning on the day of
.
I hereby authorize the (SUPERVISOR/MANAGER/PASTOR/CAMP DIRECTOR) and his/her officers, agents,
servants, or employees that are 18 years of age or older, who supervise the activities at this (CAMP, CHURCH,
SCHOOL, ETC.) into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my
child under Sections 6901, 6902, and 6910 of the California Family Code.
The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic,
medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice
of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also
extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist
licensed under the Dental Practice Act for my child.
I further authorize the (SUPERVISOR/MANAGER/PASTOR/CAMP DIRECTOR) and his/her officers, agents,
servants, or employees that are 18 years of age or older, who supervise the activities at this (CAMP, CHURCH,
SCHOOL, ETC.) to receive physical custody of my child, under Section 1283 (a) of the California Health and Safety
Code, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical
custody of my child to the (SUPERVISOR/MANAGER/PASTOR/CAMP DIRECTOR) and his/her officers, agents,
servants, or employees that are 18 years of age or older who supervise the activities at this (CAMP, CHURCH, SCHOOL,
ETC.).
-1-
FM:S812 (4-2004) MBG

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