Faith Lutheran Youth Ministries

Medical Release Form

(Please print this form and return it in person)

Name:

Date of Birth:

Parent(s):

Address:

Telephone: ( )

( )

Additional Information:

Medical Insurance Provider:

Policy #:

I (we), the undersigned parent(s)/ legal guardian(s) of______________________ a minor, do hereby authorize Faith Lutheran Church of Anaheim, CA, 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 rendered under the general of special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital.

It is understood that this authorization is given in advance to provide authority on the part of Faith Lutheran Church of Anaheim, CA to give specific consent to any and all such diagnosis, treatment, or hospital care deemed advisable by adore mentioned physician. This authorization is given pursuant to the provisions of section 25.8 of the civil code of California. I (we) release and forever discharge any and all rights of claims for any loss of personal property, or personal injuries to the fore mentioned minor.

My personal health and accident insurance shall be primarily liable for all such covered medical expenses.

I will assume the financial responsibility for any property or equipment that is damaged as a result of my child’s carelessness or negligence.

Signature: Date:

(Parent/Legal Guardian)