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Calvary Chapel of the Pass Youth 572 N. 4th St. Banning, CA 92220 Permission and Medical Consent for ______________________ (Name of Event) at ___________ (Location of event ). I hereby give permission for my child , _____________________________ (child's name) to participate in the _______________________ (name of event) on ________________ (Date of event). Transportation will be provided by licensed and insured drivers. I (we), as Parents(s) or Guardians(s), of the child named on the above consent form, do hereby authorize Calvary Chapel of the Pass, as agents 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 licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of the said physician or at the said hospital It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given in advance to provide authority and power on the part of the aforesaid agents to have a specific consent to any and all such diagnosis, treatment or hospital care which the aforesaid physician in the exercise of his or her best judgment may deem advisable. This authorization shall remain in effect through the duration of the scheduled dates and times of the Event with Calvary Chapel of the Pass, unless sooner revoked in writing, and delivered to the said agent. I further agree that Calvary Chapel of the Pass and staff are hereby relieved of all liability in the event of an accident or injury to the child stated above . _________________________ ________ ______________________________ Signature of Guardian/Self Date Phone and/or Cell # ________________________________________________________________________ Address ________________________________________________________________________ Emergency Contact ________________________________________________________________________ Health Limitations
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