WLACC HIGH ADVENTURE TEAM CONSENT TRIP SLIP AND AUTHORIZATION TO TREAT MINOR
2009 Junior Basic Backpack Awareness Course
Consent and Release:
I (we) the undersigned parent, parents, or legal guardian of ______,
a minor, do hereby give consent and permission for his participation in the scheduled High Adventure Team activities, including backpacking, hiking and camping. I understand that this event may involve strenuous physical and mental activities and to the best of my information, my son is physically and mentally able to participate in the activity. In consideration of the benefits to be derived from the aforesaid activities trips, the undersigned hereby voluntarily waive any claim against the National Council, the Western Los Angeles County Council, the WLACC HAT team, all Scout Leaders of Scouting USA and the owner and driver of the car in which my son is to receive transportation, for any and all causes which may arise in connection with the said trips or any phase or part thereof.
Date: ______Signed: ______
Parent or Guardian
Authorization to Treat Minor:
I (we) the undersigned parent, parents, or legal guardian of ______,
a minor, do hereby authorize and consent to any x-ray, examination, anesthesia, medical or surgical treatment rendered by any member of the medical or emergency room staff licensed under the provisions of the Medicine Practice Act, or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the California Department of Public Health.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care deemed advisable by the aforementioned physician in the exercise of his best judgment. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the minor patient, but that none of the above treatment will be withheld if the undersigned(s) cannot be reached.
This authorization is given pursuant to the provisions of California Family Code Section 6910 and Health and Safety Code Section 1283.
Date:______Signature: ______
Parent or legal guardian
Address: ______
City ______State ______Zip ______
List any restrictions: ______
______
Allergies to drugs or foods: ______
Any medications or pertinent information: ______
______
Telephones # where parents/legal guardian can be reach:
Father: (home) ______(cell)______(work) ______
Mother: (home) ______(cell) ______(work) ______
Family Physician ______
Address: ______
Insurance Company: ______Policy # ______
(Attach a photocopy of the applicable health insurance card and photo identification)