PLEASE FILL OUT THE MEDICAL & VIDEO/PICTURE RELEASE BELOW
First Baptist Church Parent Permission Release Form
Medical - Authorization to consent to treatment of a minor: (I) (We), the undersigned parent(s) of this minor, do hereby authorize First Baptist Church of San Diego as agent for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required by is given to provide authority and power on the part of our aforesaid agent to give special consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician, in the exercise of his best judgment may deem advisable. I realize that church insurance begins where the individual's health and accident insurance policy terminates. It is only valid when other insurance has been extended to its limits. By signing this form I give informed consent to the First Aid personnel assigned by FBCSD, who are certified in a minimum of CPR and First Aid by a nationally recognized provider in accordance with ACA standard HW-1 to provide basic First Aid and comfort measures through standardized church procedures. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This medical authorization shall remain effective through July 18th, 2011, unless sooner revoked in writing delivered to said agent.
Video/Photo - I understand that during this session of Summer Blast my child may be photographed or videotaped. By signing this release form, I am providing permission for my child to have their picture taken, or appear in a video. Pictures and video recordings will be used by the church for the sake of showing kids footage during the week of Summer Blast. We may also use the footage for future promotions and advertisements of FBCSD sponsored events. This authorization will remain effective until revoked in writing.
Parent or Guardian Signature: Actual signature is required before child can attend summer blast
Print Parent or Guardian's Name:
Parent or Guardian's Home Phone:
Work or Cell:
Child's medications taken on a regular basis:
Please list all allergies:
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