____________________________________________________________________________
Persons Authorized to pick up and/care for your child in case of emergency if parents can't be reached.
Please Provide the Name and Phone number of an out-of-state contact we can us in the event of an Earthquake.
The Parent/Guardian Accepts full responsibility for notifying Tee Divas & Tee Dudes Golf Club of Any Changes.
I, the undersigned parent/guardian of _______________________________________________, a minor, do hereby authorize TEE DIVAS & TEE DUDES GOLF CLUB (TDTD), or it’s designee as agent for the undersigned to consent to any emergency X-Ray examination, 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 and surgeon licensed under the provisions of the Medical practice Act on the medical staff of any hospital whether such diagnosis of 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 hospitalization care being required but is given to provide authority and the power on the part of our aforesaid agent to give specific consent to any and all such diagnosis, treatment or hospital care which aforementioned physician in the exercise of his/her best judgment may deem advisable. It is also understood that the parent/guardian will keep the Tee Divas & Tee Dudes Golf Club and its’ agents apprised of any medical condition that the child may develop while in the Tee Divas & Tee Dudes Golf Club organization.
This authorization is given pursuant to the Provisions of Section 25.8 of the Civil Service Code of California. I hereby authorize any hospital, which has provided treatment to the provisions of section25.8 of the Civil Service Code of California to surrender physical custody of such minor to my above named agent upon the completion of treatment. This authorization is given pursuant of Section 1283 of the Health and Safety Code of California.
