Consent for
Treatment of Minors for
Medical and
Personal Counseling Services
Any
registered students under the age of 18 will be required to have a
parental/guardian form signed before receiving any medical treatment or
personal counseling services, except in emergencies or cases exempt by state
law.
Signed
consent will be retained in the Health Services office.
The
undersigned (parent/guardian) of
(Name of Student)
hereby authorizes medical treatment or personal
counseling services by the staff of Columbia College Health Services as needed.
Birth date
of student Age _________
This
authorization is given in advance of any specific diagnosis, treatment of
medical care being required or pursuant to the provisions of Family Code
Section 6910-6911 / Section 25.8 of the California Civil Code.
_________________________
Parent/Guardian
Name (Print) Signature
(in ink please)
__________________________________
Date Semester
(Summer/Fall/Spring)
Student
Information
All areas must be
completed
Address/City/Zip
Home
Phone Cell
Phone
Emergency
Contact/Phone # Relationship
Medical
Conditions Allergies
Medical
Insurance Physician/Provider
Health Services /
Juniper Bldg. Room 2 / 209-588-5204