Santa Clara County Social Services Agency                                                                           Petition No.:

                                                                                                           Social Worker No.:

Name of Child:                                                                                                       Birth Date:
The above-named child is :                               My son                       My daughter                       A minor in my legal custody

I hereby authorize and give my consent for medical and dental care to be given to the above-named child while he or she is in the Santa Clara County Children’s Shelter
or any foster home or private institution designated by the Juvenile Court. I agree that this authorization for medical care is valid for two years from the date of
signature on this consent, unless revoked in writing by me.

Medical care shall include: the administration of any treatment deemed necessary or advisable by the physician or physicians in charge of the care of the patient,
including immunizations. The undersigned consents to any X-ray examination, laboratory procedures, medical treatment or medical clinic/hospital services rendered
the patient under the general and special instructions of the physician. For children who have been relinquished for adoption, this authorization extends to anesthesia
and surgical treatment.

It is understood by me that in case of serious illness or accident, a conscientious effort to contact the parent or legal guardian will be made before medical care is
commenced, if time and conditions permit. However, in case the parent or legal guardian cannot be located, I hereby authorize the officer of the Court or his
representatives, to secure, without delay, such medical care as may be recommended by a licensed physician.

Medical treatment is preferred as indicated in box below:
Physician of premises                             Private Physician as designated below
Name of Private Physician:                                                                                          Telephone No.:

Name of Parent or Guardian (Please Print)                                                                                 Home Telephone No.:

Address of Parent or Guardian (include City, State and Zip Code)                                                          Work Telephone No.:

Signature of Parent or Guardian                                                      Date signed                          Signature of Witness

I understand that when my child is being held in detention, I am financially responsible for all off-premises medical expenses.

Medical Insurance Company:                                                   Policy Nos.: (If OTHER, include name of Insurance Company)
   Blue Cross                                                 Medi-Cal
   Blue Shield                                                OTHER:
   Kaiser (Santa Clara)                                       Kaiser (Santa Teresa)

Is child currently under the care of a Physician?
    No                   Yes             Name of Physician:
Does child currently have any illness, injuries, or disabilities?
    No                   Yes             Please list:
Is child currently on any medication?
    No                   Yes             Please list:
Does child have any known allergies or reactions to medication?
    No                   Yes             Pollens_______                       Dust_______                  Beestings_______                   Other_______
                                         Penicillin______                     Sulfa_______                 Novocaine______                    Other_______
Record of attempt to contact parent or guardian in case of emergency:
           PARENT CONTACTED - Record in space below instructions given and received by parent.
           UNABLE TO CONTACT - Describe briefly effort made and reason unable to contact.
           JUDICIAL INTERVENTION - Note reasons why Court is authorizing medical care.

DATE:                                                       NAME:
Filing: 2nd Fastener – Right (middle)                                                                                              G:\template\forms\SCZ 1031 (c)
cc: Child’s Care Provider                                                                                                    Authorization for Medical Care – 01/09/02
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