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 ___________ Seventh-day Adventist Church, a part of the Southern California Conference of Seventh-day Adventists, located at __________________. 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
Date
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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
Please Select
United States
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Algeria
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The Bahamas
Bahrain
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Belgium
Belize
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Bolivia
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Botswana
Brazil
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Bulgaria
Burkina Faso
Burundi
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Canada
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Chad
Chile
China
Christmas Island
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Colombia
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Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
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Democratic Republic of the Congo
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The Gambia
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Laos
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Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
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Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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
Date
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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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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 _______, CA and/or the surrounding cities with teams of students and share literature. Lodging will be provided at the ______________ SDA Church located at 20335 Woodford-Tehachapi Rd., Tehachapi, CA 93561. 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 Tehachapi SDA Church and will stay until February 24, 12:00pm at the Tehachapi 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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City and State Where Signed
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