Application for participant will not be considered complete without medical insurance information.
Fill out this form only once per participant. If the participant is attending multiple overnight trips, please select ALL the applicable events below.
Any guests of participant will also be required to fill out this form.
If you have any questions regarding this form, please contact Amber Gallegos, Recreation Program Assistant at agallegos@wayfinderfamily.org.
TERMS & CONDITIONS
Authorization for Third Party to Consent to Treatment of Minor Lacking Capacity to Consent
This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all activities except as noted by me and/ or an examining physician.
I, the undersigned, parent/legal guardian of the aforementioned participant, do hereby authorize Wayfinder Family Services, Camp Bloomfield and its employees as agent (s) 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 Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned understands and agrees that Wayfinder Family Services, Camp Bloomfield and its employees shall not be legally or financially liable for any claim arising from any medical care or dental care provided pursuant to this authorization. The undersigned hereby agrees to indemnify and to hold Wayfinder Family Services, Camp Bloomfield and its employees harmless from any claim made by or on behalf of said minor arising out of any medical care or dental care provided pursuant to this authorization.
This includes authorization to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care, which is deemed advisable by and is to be rendered to the minor by or under the supervision of a dentist licensed under the provisions of the Dental Practice Act. 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 to power on the part of our aforesaid agent (s) to give specific consent to any and all such diagnosis, treatment or hospital care which a physician, meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.
I hereby authorize any hospital which has provided treatment to the aforementioned participant pursuant to the provisions of Section 25.8 of the Civil Code of California to surrender physical custody of such minor to my above-named agent (s) upon the completion of treatment. The authorization is given pursuant to Section 1283 of the Health and Safety Code of California. This authorization will remain effective while the aforementioned participant is involved or participating in any Wayfinder Family Services, Camp Bloomfield program or activities, unless revoked in writing by the undersigned and delivered to the aforesaid agent (s).
CALIFORNIA CIVIL CODE SECTION 25.8
S25.8 Minor- Consent to Furnishing of Hospital or Medical Care by Adult other than Parent - Lg. H. 1965 ch.1524
Either parent if both parents having legal custody, or the parent or person having legal custody or the legal guardian, of a minor may authorize in writing any adult person into whose care the minor has been entrusted to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medicine Practice Act or to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and provisions of the Dental Practice Act.
Type your full name to sign.
