One required for each participating Adult Leader

EMERGENCY CONSENT -- ADULT FORM
SANTA CLARA COUNTY COUNCIL, BSA
HIGH SIERRA INTERNATIONAL RENDEZVOUS '98

(A copy shall be considered as valid as the original)
Youth Name:_______________________, _________________________________              (Last name)             (First name)      (Middle Name)     Home Address:________________________________________________________             ________________________________________________________
APPROVAL AND CONSENT OF ADULT LEADER:
I, the undersigned, do hereby authorize the adult leader(s) in charge as agents for the undersigned to consent to any X-ray examination, anesthetic, medical, dental or surgical diagnosis, care or treatment and hospital care which is deemed advisable by, and is 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 accredited hospital, or a licensed dentist, as the case may be, whether such diagnosis or treatment is rendered at the office of said physician or dentist or at the said hospital, or elsewhere as circumstances may require in the discretion of the treating physician or dentist.

It is understood that this authorization is given in advance of any specified diagnosis, medical or dental care and 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, medical, dental or hospital care which the aforementioned physician or dentist, in the exercise of his best judgment, may deem advisable. This authorization is given pursuant to provisions of Section 6910 of the Family Code of California.

I understand that High Sierra International Rendezvous '98 will be covered by the news media and film or broadcasting companies, and consent to the use of my voice and/or photograph in news coverage or similar projects approved by Santa Clara County Council, BSA.

This authorization shall remain in effect until August 15, 1998 unless sooner revoked in writing and delivered to said agent(s) and will be in effect while I am en route to or from or participating in any Boy Scout program or activity including "Home Hospitality".

SIGNATURE:________________________________________ DATE:__________________

(Signature of Adult Participant)

Must be witnessed by two people:

WITNESS:______________________________ WITNESS:______________________________

Hbh: per 12-95 Em Form / Web
Revised December 30, 1997 || Posted by the Rendezvous'98 Web Crew