Authorization for Consent to Treatment of a Minor   

If your student will be a minor (under the age of 18) when s/he enrolls at HMC this fall, please complete this form.

Whenever possible, health care providers will attempt to contact the parent of a minor prior to providing emergency treatment. However, the Dean of Students staff will share this form with them when you cannot be reached in case of an emergency.

If you choose not to sign this form, emergency medical providers will provide stabilization treatment – but nothing further – until you are contacted for consent.

I/We, the undersigned parent/s of __________________________________________, a minor, do hereby authorize medical treatment including x-ray examination, anesthetic, 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 or surgeon licensed under the provisions of the Medical Practice Act.

____________________________________________________________

Signature of Parent or Legal Guardian                                             Date

Address: ___________________________________________________

                ____________________________________________________

                ____________________________________________________

Telephone:   _______________________________________________Home

                      _______________________________________________Work

                      _______________________________________________Cell

Please return by August 10, 2012 to the
Dean of Students Office, 301 Platt Boulevard, Claremont, CA 91711
or attach to an email to amy_currier@hmc.edu