Medical Consent Form
Brentwood Presbyterian Church **12000 San Vicente Blvd**Brentwood, CA 90049 Please complete the following information form for children involved in Brentwood Presbyterian Church children’s ministries. This form will become a part of Brentwood Presbyterian Church’s files for emergency and insurance purposes, in compliance with California State Law.
Child’s name:_________________________________Age:_____Sex:_____Birth date:_______________ Address:_________________________________City:___________ Zip:________Phone:_____________ Emergency Information: Parents Names:________________________________________Home Phone:______________________ Dad’s Work Phone:________________________Dad’s cell:____________Dad’s email:_______________ Mom’s Work Phone:_______________________Mom’s cell:___________Mom’s email:______________ Legal Guardian or other person having custody:________________________Home phone:_____________ Address:______________________________City:___________zip:__________Work phone:___________ Alt. Emergency Contact:______________________Home Phone:____________Work phone:__________ Allergies:____________________________Special Medication:__________________________________ Other (activity restrictions, etc.):____________________________________________________________ Physician’s name:_____________________________________Office phone:________________________ Health Insurance Co:__________________________________Policy number:_______________________
Parent Waiver and Medial Treatme nt Release:
I (we), the undersigned parent(s) or legal guardians of (please print child’s full name) ____________________give permission for my child, a minor, to attend activities sponsored by Brentwood Presbyterian Church. I understand that they will be participating in events on equipment that could possibly result in major and/or minor injury to my child, for which I agree not to hold the Brentwood Presbyterian Church responsible. I also understand that I may be held responsible for any damage or injury to others caused by my child. I further do hereby authorize and consent to have any x-ray examinations, anesthetic, medical or surgical diagnosis and treatment and emergency hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act, and on the staff of any acute medical hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power to render care, which the aforementioned physician, in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the child, but any of the above treatments will not be withheld if the undersigned cannot be reached. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. It is further understood that the undersigned will assume full financial responsibility for all expenses incurred for any of the foregoing services.
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Signature of Parent or Legal Guardian Date Signature of Parent or Legal Guardian Date
Activity Guidelines for Kids: Brentwood Presbyterian Church desires to provide a safe, respectful, fun, nurturing and safe place for children and adults. We ask that parent and child read, discuss and sign the following guidelines:
__I will show respect and kindness to other children and to my leaders and will listen to and obey my leaders. __I will take care of church property and supplies. __I will not bring toys, food, scooters, skateboards, gum, candy or electronic games with me. __I understand that if I continually misbehave, my parents may be called.
Signature of Child Date
Signature of Parent or Legal Guardian Date