TODAY'S DATE: April 22, 2021
MEDICAL RELEASE FORM
For all activities sponsored by Calvary Chapel Modesto from June 1, 2020 thru August 31, 2021
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, 2020, and remain in effect until 12:01 AM on August 31, 2021, 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).
The young people that participate in the youth activities at Calvary Chapel are representing the Lord Jesus Christ, the fellowship of Calvary Chapel and their families. The following standard of dress and conduct will be expected of any person participating in the youth activities of Calvary Chapel:
- No illegal, non-prescription drugs (including alcohol or the use of tobacco) will be permitted.
- No weapons of any kind are permitted.
- Modest apparel must be worn at all times. No midriff, halter tops, or two-piece swim suits, etc. will be permitted.
- No public displays of romantic affection will be allowed among unmarried couples.
As the PARENT of a youth participant in a Calvary Chapel activity, I understand the standard of dress and conduct expected of my child.
As a YOUTH participant in a Calvary Chapel activity, I understand the standard of dress and conduct expected of me.