Jews in the Wilderness
2023-2024/ 5784
Please complete a separate Treatment Consent form for each child you are registering in Jews in the Wilderness.
All items with a red * are required. When done, click on "Submit" at the bottom.
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 and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his/her best judgement may 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 below-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 authorizations shall remain effective until 6/30/2023 unless sooner revoked in writing delivered to said agent(s).