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Calvary Chapel Modesto

4300 American Ave

Modesto CA 95356

(209) 545-5530

TODAY'S DATE: December 11, 2018

MEDICAL RELEASE FORM

For all activities sponsored by Calvary Chapel Modesto from June 1, 2018 thru August31, 2019

The undersigned, parent/legal guardian of (minor), herein authorizes the adult sponsor of Calvary Chapel Modesto for the stated activity(ies) or any responsible adult person bearing this written authorization, into whose said care the above mentioned minor child 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 California Family Code.

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 said adult person to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician or dentist in the exercise of his best judgment may deem advisable.

This authorization will begin on June 1, 2018 and remain in effect until 12:01 AM on August 31, 2019 unless sooner revoked in writing and delivered to the adult sponsor. My signature on this Medical Release Form constitutes my permission for the above named minor to participate.

Parent or Guardian Signature:

CALIFORNIA FAMILY CODE SECTION 6910 AUTHORIZATION OF MEDICAL TREATMENT OF MINORS

Either parent (if both parents have 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 provisions of the Medicine Practice Act or to consent to an x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to said minor by a dentist licensed under the provisions of the dental Practice Act (Family Code 6901, 6902).

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Fall '18 Grade: *
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Type of Medical Release
Please choose one type:*
Use this for all Calvary Chapel Modesto Activities
Use this for Vacation Bible School only.
Insurance/Emergency Conact Information

Parent's Cell Phone:

Health Insurance Co. & Policy #:

Group Card #:

Insurance Subscriber's Name:

Subscriber's DOB:

Add'l Emergency Contact :

Phone:

Relation:

Special Diet/Medications/Allergies, etc.:
Photo Permission Release
Yes, I hereby grant permission to Calvary Chapel Modesto to photograph and video tape my minor child, and to use the images in activities for publications, videos, promotions, and the Calvary Chapel Modesto websites.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Fall '18 Grade: *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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