Diocese of Stockton

Emergency Health / Medical Information and Consent

In the event of an emergency, I, the undersigned parent/guardian of the child named on this form, hereby gives permission to the Roman Catholic Bishop of Stockton, the Pastor, employees, agents, representatives, Chaperons and adult volunteers (the Designated Person(s)) to arrange for and authorize emergency medical, dental, or surgical treatment for my child, as considered necessary by the attending physician or dentist. I wish to be advised prior to any further post-emergency treatment by the hospital, doctor or dentist.