Youth Waiver - Episcopal Diocese of San Diego Youth Waiver - Episcopal Diocese of San Diego

Youth Waiver

Parental Permission and Medical Authorization Form

I give permission for my child (named below) to attend the events, field trips, and service projects associated with the Episcopal Diocese of San Diego.  I further give permission for my child to be transported to and from events by hired and volunteer drivers authorized by the Episcopal Diocese of San Diego.

Medical Release

I hereby authorize the Youth Group leaders, volunteers, the Episcopal Diocese of San Diego, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child.  This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.

Custody Release

I further authorize the Youth Group leaders of the Episcopal Diocese of San Diego to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to said adult.

Activity Release

I further give permission for my child to participate in all activities sponsored by the Youth Group or the Episcopal Diocese of San Diego, except as noted:

Youth Waiver

Emergency Contact Information

Home, Mobile, etc.
Home, Mobile, etc.
Home, Mobile, etc.
Home, Mobile, etc.

Health Care Information

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