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PASADENA CITY COLLEGE
STUDENT HEALTH SERVICES
1570 E. Colorado Blvd. D-105
Pasadena, California 91106
626-585-7244
MINOR AUTHORIZATION CONSENT FORM
FOR MEDICAL TREATMENT &/OR COUNSELING
Please submit this form to Admissions in L113, via fax 626-585-7915 or
email to: enrollme@pasadena.edu
Student Name (Please Print) Last 8 digits of Lancer ID card
Address City Zip
Phone
Person to notify in an emergency Relationship
Medical Insurance (include MediCal) ________________________________________________
Name of Physician ___________________________________ Phone Number ______________
Student’s Date of Birth __________ Age _________ Male [ ] Female [ ]
The undersigned (parent/guardian) of ______________________________, hereby
(Print Student Name)
authorizes the medical and counseling staff of Pasadena City College and/or
Student Health Services, as agents for the undersigned to consent to any diagnostic
procedure (including x-rays) to the administration of any counseling, medical,
surgical treatment, or to any hospital care when any or all of the foregoing is deemed
advisable and is to be rendered under the general supervision of any physician and
surgeon licensed under the provisions of the Medical Practice Act.
This authorization is given in advance of any specific diagnosis, treatment or
medical care being required and pursuant to the provisions of Section 25.9 of the
California Civil Code.
Parent/Guardian Name (Please Print) Signature
Date Home Telephone Number Work Telephone Number
Word/forms/minor
Rev. 08/13
