2024 Medical Release Form - Minor
Student Information
Full Name
*
First Name
Middle Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Parent/Guardian Information
Mother
First Name
Last Name
Father
First Name
Last Name
Emergency Contact Information
used if parent/guardian is unreachable
Emergency Contact Name
*
First Name
Last Name
Relationship
*
e.g. neighbor, friend, aunt, grandfather, etc.
Phone Number
Phone Number
-
Area Code
Phone Number
Medical Information
Health Issues
if none, enter "N/A"
Known Allergies
if none, enter "N/A"
Additional Instructions
Agreement
*
(I, We) hereby give permission for my child to participate in the student activities of Neighborhood Bible Church. (I, We) the undersigned parent(s)/person having legal custody/legal guardianship of the above-mentioned student, a minor, do hereby authorize Neighborhood Bible Church as agent for the hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority of power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnoses, treatment or hospital care which a physician, meeting the requirements of this authorization, may in the exercise of her/his best judgment, deem advisable. The authorization is given pursuant to the provisions of Section 56.11 of the Civil Code of California. (I, We) hereby authorize any hospital which has provided treatment to the above-named minor(s) pursuant to the provision of Section 56.11 of the Civil Code of Californian to surrender physical custody of such minor to (my, our) above named agent upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California. These authorizations shall remain effective until December 31, 2020 unless sooner revoked in writing delivered to said agent(s).
Signature
Date
-
Month
-
Day
Year
Date
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