GLOW IMPACT | ACADEMY EDITION
Authorization for Medical Treatment for Minors & Parental Consent Form
Authorization for Medical Treatment for Minors
Name of Student
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First Name
Last Name
Name of Parent / Legal Guardian
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First Name
Last Name
Email of Parent / Legal Guardian
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example@example.com
Home Phone Number of Parent / Legal Guardian
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Area Code
Phone Number
Cell Phone Number of Parent / Legal Guardian
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Area Code
Phone Number
I am the parent or legal guardian of the child (name of student) listed in this form, referred to as "my child." My child is attending and participating in GLOW IMPACT – Academy Edition activities at the Pasadena Seventh-day Adventist Church, a part of the Southern California Conference of Seventh-day Adventists, located at 1280 E. Washington Blvd. Pasadena, CA 91104. All GLOW IMPACT – Academy Edition activities will be organized and run by the Literature Ministries Office of the Southern California Conference of Seventh-day Adventists. I authorize the GLOW Impact Academy Edition Coordinator and his/her officers, agents, supervisors, servants, or employees who are 18 years of age of older, who supervise the activities at this organization into whose care my child has been entrusted, to consent to medical 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 radiological (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 California laws or equivalent statutes of other States, for my child. I further authorize the GLOW Impact Academy Edition Coordinator and his/her officers, agents, supervisors, servants, or employees who supervise the activities of the organization 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 custody of my child to the Pastor and his officers, agents, servants, or employees who are 18 years of age or older who supervise the activities at this organization. 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 Coordinator and his/her authorized designee, to exercise his or her best judgment on what is advisable for my child’s care, upon advice of such physician, dentist and surgeon. A photocopy of this authorization shall be as valid as the original. This Authorization shall remain valid during the dates of February 21-24, 2020 while under the supervision of the GLOW Impact Academy Edition Coordinator and authorized supervisors. The information that follows contains the complete and accurate health and emergency information to assist in providing assistance to my child.
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Date Signed
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
City & State Where Signed
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Health & Emergency Information
My Child's Information
Full Name of Student
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First & Middle Name
Last Name
Home Address of Student
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
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Area Code
Phone Number
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Health Insurance Company
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Name of Insured
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Insurance ID Number
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Allergies or medications being taken:
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Please send a photo-copy of
Address of Parent / Legal Guardian (If different than address for minor)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parental Consent
Name of Student
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First Name
Last Name
Name of Parent / Legal Guardian
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First Name
Last Name
I am the parent or legal guardian of the child (name of student) listed in this form, referred to as "my child." My child wishes to and I consent and give permission for my child to participate in the function listed below. The function is sponsored and supervised by Southern California Conference Literature Ministries, a ministry which is a part of the Southern California Conference of Seventh-day Adventists. I understand that this consent and permission shall extend to related activities and, if necessary, for the transportation of my child to and from the function site. I have been given the opportunity to ask questions of the supervisors of this function. My child and I further understand and assume the risk of injury (including death) to my child due to the inherent risks of these activities. I have signed an Authorization for Medical Treatment form and completed the Health and Emergency Information Supplement for my child. The information regarding the function which is the subject of this consent and for which I am giving permission for my child to participate is as follows: Sponsoring Organization: Southern California Conference Literature Ministries. Description and Location of function: GLOW IMPACT Academy Edition - A weekend mission trip to knock on doors in Pasadena, CA and/or the surrounding cities with teams of students and share literature. Lodging will be provided at the Pasadena SDA Church located at 1280 E. Washington Blvd. Pasadena, CA 91104. Meals, transportation to and from the function site for missionary activities, literature for distribution, training and supervision will be provided. Date and times of function: Students are expected to arrive either via transportation provided by their school & sponsors or parents / legal guardians on February 21, 4:00pm at the Pasadena SDA Church and will stay until February 24, 12:00pm at the Pasadena SDA Church. Students will return to their school via transportation provided by their school & sponsor or will be picked up by their parent / legal guardian. If the school provides transportation, please see school sponsor or chaplain for details on arrival and return times. Examples of activities related to the function: Students will participate in group icebreakers and activities to get to know other students participating in GLOW Impact. Students will take part in worship services, meal time, and training for the mission activities of the day. Students will ride in provided transportation to their designated neighborhood of the city everyone will be working in. Students will go door-to-door in neighborhoods or public places sharing literature with people. Supervisors will be continuously working with and supervising their team. All students will have safety radios in good and working condition for immediate contact at all times. Students will enjoy breaks as needed and breaks for meals to eat with their team. Students will return from their neighborhood to the function site at the end of the day for dinner, relaxation, free time and worship. A nightly curfew will be consistently kept with intentional supervision. How to contact us during the function: Feel free to call or text Marco Topete, GLOW Impact Academy Edition Coordinator at (408) 512-6960 for any questions during the function. You may also contact the school sponsor assigned to this function.
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
City and State Where Signed
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Submit
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