Consent to Medical Care and Treatment of Minor Children
(Form should be completed for each Sr. & Jr. YBA attendee)
Health care providers often cannot treat or care for children without consent
from parents or legal guardians. This can cause problems when parents or
guardians cannot be reached by the provider to obtain consent in non-
emergency situations, or when further treatment is indicated after an
emergency has been stabilized. An advance authorization for the person(s)
caring for your child can help in these situations. Such an authorization also can
be useful in emergency situations, even though consent to treat is generally
implied in emergency situations.
I, ____________________________ the natural parent/legal guardian
of _________________________________________ authorize and
consent to medical, surgical and hospital care, treatment and procedures to be
performed for my child by a licensed physician or hospital when deemed
necessary or advisable by the physician to safeguard my child’s health and I
cannot be contacted. I understand that consent to treat is generally implied in
emergency situations, and I waive my right of informed consent to such
treatment as well as to further treatment that the physician would deem
advisable during the time I cannot be contacted.
Please complete one form per child
Child’s Name:
Date of Birth:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Temple:
Allergies (including drug reactions):
Chronic Illnesses:
Regular Medications:
Date of Last Tetanus:
Child’s Physician:
Physician’s Phone:
Parents/Guardians Names:
Phone:
Witness:
Phone:
Insurance:
Employer:
Group Number:
Membership Number:
Signature of Parent/Guardian:
Code of Ethics
Violation of any of the following provisions will be investigated and individuals
may be requested to leave the site of the convention with forfeiture of
expenses otherwise provided by the Seattle Betsuin Young Buddhis