ࡱ> .0-5@ bjbj22 "XX6666666J2222 >J^^^^^^^^prrrrrr$R n6^^^^^66^^:::^ 6^6^p:^p::H66H^R "2hHp0Hg :g HJJ6666g 6H(^^:^^^^^JJD0 JJAUTHORIZATION TO TREAT A MINOR (This authorization will be kept with the team coach) I (We) the undersigned parent, parents or legal guardian of ________________________, Please print name a minor, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical treatment rendered by any member of the medical or emergency room staff licensed under the provisions of the Medical Practice Act, or dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State in which the hospital is located. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care deemed advisable by the aforementioned physician in the exercise of his best judgment. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient but that none of the above treatment will be withheld if the undersigned cannot be reached. This authorization is given pursuant to the provisions of Section 25.8 of The Civil Code of California. Date:_______________ Insurance Co.____________________________________________ _________________________________________________________ Parents Name please print (signature) Address:_________________________________________________ Street appt # City Zip List any Restrictions:____________________________________________ Birth date:_____________________ Last Tetanus:______________________ Allergies to Drugs or Food:_______________________________________________ Special Medications or Pertinent Information:_____________________________________________________________ Telephone Numbers: Father:_______________________________________ Home Work Mother:_______________________________________ Home Work Family Physician:_______________________________________________ Name Phone hiJh:6 VW   9 : u gh ^`gd:6gd:6$a$gd~qPh%Tcgd:6 1h/ =!"#$%@@@ NormalCJ_HaJmH sH tH DAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List  VW9:ugh%Tc00000000000000000 0p0000 000000 0 000(0 0%TcO900͡M90M90M90O90 h  AC68+-su33333333333uhcm:6~qP"iJ@@@UnknownG: Times New Roman5Symbol3& : Arial"h##''Y243H)?"AUTHORIZATION TO TREAT A MINORcmcmOh+'0x  4 @ LX`hpAUTHORIZATION TO TREAT A MINORUTHcmHmHmHNormalZcmm2mMicrosoft Word 10.0@F#@;{@;{'՜.+,0 hp|  ctmA AUTHORIZATION TO TREAT A MINOR Title  !"#$&'()*+,/Root Entry Fp?1Data  1TableWordDocument"SummaryInformation(DocumentSummaryInformation8%CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q