Jane Addams Peace Camp medical release form


You may either print and mail in this form now,
or complete it on the first day of camp.
We are required to have this completed form
for your child to participate at camp.




CHILDS NAME: _________________________________

PARENT: _______________________________________

Medical Release Policy: CONSENT TO TREAT A MINOR
I/We, being the parent(s) or legal guardian(s) of the above named child,
do herby appoint the staff of the Jane Addams Peace Camp
to act in my/our behalf in authorizing any X-ray, anesthetic, medical,
dental or surgical diagnosis or treatment and hospital care for
the above named minor during my/our absence.

This document is valid during August 2017.

This document may be relied on by any licensed physician, surgeon,
dentist or appropriate hospital representative in accordance
with section 25.8 of the Civil Code of California. I/We authorize any
hospital which has treated the above minor to surrender
physical custody of the minor to my/our/above named agent. This
authorization conforms to Section 1283 of the
Health and Safety Code of California.

 

Parent's Signature:  __________________________________________    Date: _______________
 

Parent's Printed Name: _________________________________________