Cerritos Community College District
Medical Consent Minor (under age 18)
In the event of any medical emergency, I grant to Cerritos College or any of its representatives
on the trip the full authority to take any action deemed necessary to protect the health and safety
of __________________________________ at my expense, including, but not limited to,
(Name of minor participant)
placing minor participant under the care of a doctor or in a hospital at any place for medical
examination and/or treatment, or returning minor participant to my home city at my own expense
if such return is deemed necessary after consultation with medical authorities.
The student participant is under the age of 18. His/Her birth date is: ____________________.
Name of Conference: ______________________________________.
Date of Conference: ______________________
Name of Participant
Student Number
Name of authorized Parent/Guardian
Signature of Authorized Parent/Guardian
Phone Number
Cell Phone Number
In case of emergency please contact: _______________________________________________ .
Relationship to participant: _______________________ Phone number: ___________________
Medical insurance carrier: ____________________________________________
Policy Number: __________________________________________
Please list any prescription medication: _________________________________________