VFW Youth Volunteer Group

Authorization for third party to consent to 
treatment of a minor lacking capacity to consent

(I) 	(We), the undersigned, parents(s) / person(s) having legal custody / legal guardianship of:

 (Player's Name)

minor, do hereby authorize

as agent(s) for the undersigned to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority to power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care, which a physician meeting the requirements of this authorization , may, in the exercise of his/her best judgment, deem advisable.

This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

(I) 	(We) hereby authorize any hospital which has provided treatment to the above named minor pursuant to the provisions of Section 25.8 of the Civil Code of California to surrender physical custody of such minor to (my) (our) above named agent(s) upon the completion of treatment.  This authorization is given pursuant to Section 1283 of the Health and Safety Code of California

These authorization shall remain effective until:  _________________, 20___, unless sooner revoked in writing and delivered to said agents(s).
 
MOTHER or	  					FATHER or 
GUARDIAN  	  GUARDIAN 	
(Both must sign)
ADDRESS  	

PHONE	    		DATE:  	
	(Home)	(Business or other emergency number)
FAMILY DOCTOR  		  PHONE  	
	(Name)
	ADDRESS  	

	DRUG ALLERGIES (if any)  	

INSURANCE COMPANY 		POLICY #:	
	PRIMARY INSURED 	

This form must be filled out completely and is to be retained by the supervising VFW representative for this child and must be available at his or her participating activity.