2023 GUEST CHURCH - Youth Camp Parental Consent

2023 Youth Camp - GUEST CHURCH

Permission to Participate - Authorization for Medical Treatment - Release & Liability - FOR GUEST CHURCHES ONLY
General Information - FOR GUEST CHURCHES ONLY
Participant's Full Name*

First NameLast Name
Participant's Birth Date*

MonthDayYear
Date
Name of Church
Participant Cell Number
Parent/Guardian Information
Parent/Guardian Full Name*

First NameLast Name
Cell Number*
Please enter a valid phone number.
Work Phone
Parent Email*
example@example.com
Parent/Guardian Full Name

First NameLast Name
Cell Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Additional Info

0/90
Medical Information
Medical Insurance Company*
Insurance Policy Number*
Any food, medical, or environmental allergies?*
List any Medical Problems (asthma, seizures, headaches):*
Significant Medical History (surgery, injuries, serious illness)*
Is any medication required?*

YesNo
If yes, list any medications taken regularly and directions:
Blood type:
Authorization for Medical Treatment

Please read and sign below in agreement.
I am the parent or legal guardian of PARTICIPANT named above (hereinafter "my child"). My child is attending and participating in activities at CACHUMA LAKE. (hereinafter "this camp," "church," "school," etc.) located at: 1 Lakeview Dr., Santa Barbara, CA 93105 beginning on the day of June 26, 2023.

I hereby authorize the CAMP DIRECTOR Pastor Luis Parada and YOUTH LEADER Ronnie Reynoso and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP 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 CAMP DIRECTOR and YOUTH LEADER and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP 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 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.

It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.
Please Print Name of Parent/Guardian and sign below for medical authorization*

First NameLast Name
Signature for authorization for medical treatment*

Clear
Emergency Contacts (if parent/guardian cannot be reached)
If, in the event of a medical or other emergency, I am unable to be reached by telephone at my home or work telephone numbers listed below, I authorize the activity supervisor(s) to attempt to contact me through the emergency contacts listed below.
Emergency Contact #1 Name*

First NameLast Name
Relationship*
E-mail*
example@example.com
Cell Phone Number*
Release and Liability
I am the parent or legal guardian of PARTICIPANT named above (hereinafter "my child"). My child is attending and participating in activities at CACHUMA LAKE. (hereinafter "this camp," "church," "school," etc.) located at: 1 Lakeview Dr., Santa Barbara, CA 93105 beginning on the day of June 26, 2023.

I hereby authorize the CAMP DIRECTOR Pastor Luis Parada and YOUTH LEADER Ronnie Reynoso and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP 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 CAMP DIRECTOR and YOUTH LEADER and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP 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 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.

It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.
Print Name of Parent/Guardian and Sign in agreement to Release/Waiver*

First NameLast Name
Signature of Release/Waiver*

Clear
Requirements
The child named above is in good health and has no physical or medical limitations that would prohibit your child from participating in the meals, activities, church services, and any other gatherings. Parents/guardians should specify allergies and medical problems in section above.
Transportation
Guest Churches are responsible for securing their own rides for their participants to and from Cachuma Lake.

Arrival (Cachuma Lake) - Monday, June 26, 11:00 AM

Departure (Cachuma Lake) - Friday, June 30, 11:00 AM
Consent
I hereby attest that I am (we are) the legal parentguardian(s) of the above-named child and hereby consent to the child's participation in the activities described above. I understand that activities of the kind described above may result in physical injury to my child but nonetheless specifically request that he or she be allowed to participate in those activities.
Insurance
I/We understand that Bible Baptist Church of Long Beach, does not carry any insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my own insurance carrier; or (b) that I/We am personally financially responsible for any and all medical costs incurred as a result of the child's injury.
PLEASE CLICK AGREE AND SIGN BELOW IN AGREEMENT
I, the parent/guardian, hereby attest that I have carefully read this Permission to Participate, understand its contents, and agree to its terms and conditions.*

I agree
Date*

MonthDayYear
Date
Print Name of Parent / Guardian and sign below in agreement*

First NameLast Name
Signature*

Clear
Should be Empty:

2023 Youth Camp - GUEST CHURCH

General Information - FOR GUEST CHURCHES ONLY

Parent/Guardian Information

Medical Information

Authorization for Medical Treatment

Emergency Contacts (if parent/guardian cannot be reached)

Release and Liability

Requirements

Transportation

Consent

Insurance

PLEASE CLICK AGREE AND SIGN BELOW IN AGREEMENT