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California State University, Chico
Student Health Service
Chico, CA 95929-0777
Phone (530)898-5241
Fax (530)898-4057
CONSENT FOR TREATMENT OF A MINOR
I give authorization to the Student Health Service at California State University, Chico to
provide, upon request of my minor son/daughter,
Name
Date of Birth
all ordinary examinations and medical treatment until he/she reaches 18 years of age.
I also give my permission for the Student Health Service personnel to authorize any
necessary emergency care prior to the time I can be reached to give permission.
Date Signature of Parent/Guardian
SHS STAFF USE ONLY FOR TELEPHONE CONSENT
Parental/guardian authorization given
Date and time of consent:
Date
Time
□ Yes □ No
Method of verification of identity
Call to
Home Work
□ □
Complete all that apply
Student’s name Student’s DOB
Parent/guardian name
Parent/guardian address
Home phone number Work phone number
Staff Signature Date
Minor Consent 07/2005
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