Roots Youth Fellowship - Event Permission Slip
*Authorization and Consent to Treatment for Minor Form*
Pursuant to California Civil Code Section 25.8 and California Penal Code Section 12552
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Email *
What event is this for?
Date of event?
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The undersigned to hereby authorize Seeds of Life Church or such substitute as he/she may designate as agent for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the below minor(s) which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon licensed under the Provision of Medicine Practice Act, or of any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, or at a hospital, or elsewhere.  Further, we give permission for the below minor(s) to participate in all regular activities of Seeds of Life Church.
This authorization will remain effective while the below minor is en route to or from or involved or participating in the activity described above, unless revoked in writing by the undersigned, and delivered to the aforesaid.
First & Last Name of Minor-1
First & Last Name of Minor-2 (if applicable)
First & Last Name of Minor-3 (if applicable)
First & Last Name of Minor-4 (if applicable)
Minor's Cell Phone (if applicable -- list name with number if this form is for multiple children)
Home Phone number
Home Address (number and street)
City
Zip
Father or Guardian full name
Father or Guardian best contact phone number
Father or Guardian email address
Mother or Guardian full name
Mother or Guardian best contact phone number
Mother or Guardian email address
Today's Date
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Please use the following space below to write down any additional information that might be pertinent to the above referenced minor (e.g. medical condition, special medication, etc.):
Please make sure to CLICK "SUBMIT" below to have your form recorded.  Thank you for taking the time to fill this out! 
You should also be receiving an email confirmation in the email you provided in the very beginning section. We appreciate all the prayer support as we look ahead to a great event!
A copy of your responses will be emailed to the address you provided.
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