Form Fm S812 - Authorization For Medical Treatment printable pdf download

Form Fm S812 - Authorization For Medical Treatment

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.).

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FM:S812 (4-2004) MBG

Form Fm S812 - Authorization For Medical Treatment