Chrysalis Application
Page 2 of 2PARENT/GUARDIAN MUST COMPLETE FOLLOWING AUTHORIZATION FORM
--------------------------UNDER 18 YEARS OF AGE-----------------------------
_______________________________ has my/our permission to attend the Chrysalis weekend.
In the event of emergency: I (WE) THE UNDERSIGNED PARENT(S) OR GUARDIAN(S) OF ____________________________, A MINOR, DO HEREBY AUTHORIZE AND CONSENT TO ANY X-RAY EXAMINATION, ANESTHESIA, MEDICAL OR SURGICAL DIAGNOSES OR TREATMENT UNDER THE GENERAL OR SPECIFIC SUPERVISION OF ANY MEMBER OF THE MEDICAL STAFF AND EMERGENCY STAFF LICENSED UNDER THE PROVISIONS OF THE MEDICINE PRACTICE ACT, OR A DENTIST LICENSED UNDER THE PROVISIONS OF THE DENTAL PRACTICE ACT, OR THE STAFF OF ANY ACUTE GENERAL HOSPITAL HOLDING A CURRENT LICENSE FROM THE STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, TO OPERATE A HOSPITAL. 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 BEST JUDGMENT, MAY DEEM ADVISABLE. IT IS UNDERSTOOD THAT EFFORT SHALL BE MADE TO CONTACT THE UNDERSIGNED PRIOR TO RENDERING TREATMENT TO THE PATIENT, BUT THAT ANY OF THE ABOVE TREATMENT 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.
List any RESTRICTIONS: _______________________________________________________
This consent shall remain in effect until Date __________________
SIGNATURE OF PARENT(S) OR GUARDIAN(S) __________________________________________________DATE _____________ __________________________________________________DATE _____________
In the event you need to be reached during the weekend (include area codes):
Home Phone: ______________________ Office: __________________________
Cellular: __________________________ Emergency#: _____________________
PLEASE LIST ANY ALLERGIES, MEDICATIONS BEING TAKEN, MEDICAL PROBLEMS, SPECIAL NEEDS, OR
OTHER PERTINENT INFORMATION.
Include times medicine is taken.
Special diet:
Return to sponsor:
Mail to: John Eveland, 620 A Telegraph Canyon Road, Chula Vista, Ca. 91910-6547