Consent to Medical Care and Treatment of Minor Children
(Form should be completed for each Sr. & Jr. YBA attendee)

Health care providers often cannot treat or care for children without consent from parents or legal guardians. This can cause problems when parents or guardians cannot be reached by the provider to obtain consent in non-emergency situations, or when further treatment is indicated after an emergency has been stabilized. An advance authorization for the person(s) caring for your child can help in these situations. Such an authorization also can be useful in emergency situations, even though consent to treat is generally implied in emergency situations.

I, ______the natural parent/legal guardian

of ______authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician or hospital when deemed necessary or advisable by the physician to safeguard my child’s health and I cannot be contacted. I understand that consent to treat is generally implied in emergency situations, and I waive my right of informed consent to such treatment as well as to further treatment that the physician would deem advisable during the time I cannot be contacted.

Please complete one form per child
Child’s Name: / Date of Birth:
Address:
City: / State: / Zip:
Home Phone: / Cell Phone: / Temple:
Allergies (including drug reactions):
Chronic Illnesses:
Regular Medications: / Date of Last Tetanus:
Child’s Physician: / Physician’s Phone:
Parents/Guardians Names:
/ Phone:
Witness: / Phone:
Insurance: / Employer:
Group Number: / Membership Number:
Signature of Parent/Guardian:

Code of Ethics

Violation of any of the following provisions will be investigated and individuals may be requested to leave the site of the convention with forfeiture of expenses otherwise provided by the Seattle Betsuin Young Buddhist Association. If deemed necessary by the chaperones, parents will be responsible for immediately coming to the convention site to take care of their son/daughter.

1.  Illegal drugs and alcohol of any kind are prohibited.

2.  Everyone must respect the rights and property of other participants and the hotel.

3.  Each participant must be within the confines of the activities specified at agreed times and obey the 1:30 am evening curfew.

4.  Each participant is responsible for their behavior and actions to their peers, chaperones, and advisors.

5.  Each participant is responsible in letting their chaperones/advisors know as to his/her whereabouts at all times.

Waiver Form

We have read and will abide by the responsibilities and code of ethics provided. We agree not to hold the Seattle Betsuin Young Buddhist Association or the Seattle Betsuin Buddhist Temple responsible in any way should injury, loss of property or any other mishap occur. I acknowledge that I will be held responsible for my own actions and I will agree to respect the property of others as well as of the facility.

Student Signature: / Date:
Parent/Guardian Signature: / Date: