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Valencia High School “Pride of the Viking Choirs” Medical
Release Form Heritage Festival and Tour to New York,
April 13th – April 19th, 2006 AUTHORIZATION
TO CONSENT TO TREATMENT OF A MINOR I (We), the undersigned, parent (s) of
________________________, a minor, to hereby authorize Mrs. Christine Enns, choir
director, as agent for the undersigned to consent to any x-ray examination,
anesthetic, medical or surgical diagnosis or treatment and hospital care which
is deemed advisable by, and is to be rendered under the general or special
supervision of any physician or surgeon licensed under the provisions of the
Medicine Practice Act on the Medical Staff of a licensed hospital, whether such
diagnosis or treatment is rendered at the office of said physician or at said
hospital. I assume full responsibility for payment for such treatment either
individually and /or via insurance for payment for such treatment either
individually and/or via insurance as is listed below: Name of Employer:__________________________________________
Insurance Company__________________________________________ Name of HMO:_____________________________________________ Name Of
Physician:__________________________________________ Group Number:_____________________________________________ Policy Number:_____________________________________________ 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 on the part of our afore said agent (s)
to give specific consent to any and all such diagnosis, treatment, of his/her
best judgment may deem advisable, This authorization is given pursuant to the
provisions of Section 25.8 of the Civil Code of California and shall remain
effective until July 1, 2006. The physical conditions,
allergies, and /or “patient history” listed below should be considered by
any physician when recommending treatment or formulating diagnosis: The student identified above is
currently taking the following
medications:_____________________________________________________________________________________________________________________________________________________________________________________________________________ Parent / guardian
signature(s)__________________,________________Date_________ Parent / Guardian Printed
Names______________________,_______________________ Witness Signature____________________, Printed
Name_______________, Date_____ |
