Authorization and Consent for Medical Treatment

 

Chapter safety policy requires that minors have available an Authorization and Consent for Medical Treatment for use by the Trip Leader in the event of injury or illness. Print out and fill in the form below and carry it on all Angeles Chapter trips.


Minor's Full Name: _____________________________________
Minor’s Age: _____________________________________
Minor's Address: _____________________________________
City: _____________________________________
Zip: _____________________________________

Authorization and Consent

The Undersigned do hereby authorize the Sierra Club Trip Leader or such substitute as may be designated as agent for the Undersigned to consent to any x-ray, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by and is to be rendered under the Provision of Medical Practice Act or by any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere.

Parent or Guardian: _____________________________________
Parent or Guardian: _____________________________________
Witness: _____________________________________
Date: _____________________________________
Address of Parent or Guardian: _____________________________________
Phone: _____________________________________
Insurer: _____________________________________
Account Number: _____________________________________