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2277 Rosecrans St, San Diego, CA 92106



I undersigned, request that my child, ________________________________________,

Who is in the _____________, be permitted to participate in the Jr. High
Ministry: _____________________________________________________
Date:________________ Drop off:_____________________ Pick up______________

I hereby waive all claims, which I might have against The Rock Church, their agents and
employees, for injury, accident, illness or death occurring during or by reason of the above
The person to contact in the case of an emergency is:

Phone number is _________________________

Signature of parent or guardian ___________ ______________ ______________

Authorization to Consent Treatment:

(I)(We) (Parents)(Guardian) of the child named above do hereby authorize The Rock Church
as agents for the undersigned consent to any x-ray examination, anesthetic, medical or
surgical diagnosis or treatment and hospital care which is deemed advisable by and is
rendered under the general of specific supervision of any physician or surgeon licensed under
the provisions of the Medical Practice Act on the medial staff of a licensed hospital rather
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 of hospital care required, but is given in advance to provide authority and power on
the part of the afore said agents to give specific consent to any such diagnosis, treatment or
hospital care which the afore said physician in the exercise of his best judgment may deem
advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil
Code of California.

Signature of Parent or guardian__________________________ Date _____________