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SunHouse Medical Release Form:

This form is valid with SunHouse for one year.

Today's Date

YYYY

Students Name

First Name

Last Name

Birthdate

YYYY

Grade

School

Allergies

(If none, please write NONE)

Activities

My student can fully participate in all activities, except for the following: (If none, please write NONE)

Parent Information

Mother's Name

First Name

Last Name

Mother's Addres

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Name

First Name

Last Name

Father's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Alternate Emergency Contact

First Name

Last Name

Relationship to Child

Telephone Number

(###)

###

####

Pursuant to California Family Code §6910, I, ________________________________, a parent having legal custody of _________________________________, a minor child, hereby authorize the adult leaders of the La Jolla Pres youth program into whose care such minor child has been entrusted, to consent to any X-ray examination (or similar examination such as by CAT scan), anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act. I agree to pay any and all costs for the foregoing.

Medical Insurance Provider

Insurance certificate number and/or group number.

Primary Care Physician

Primary Care Physician Office Number

(###)

###

####

I agree that the forgoing is true and correct. I give consent for my child to be treated.

Yes

Parent Digital Signature