2340 Pepper Street

Sutter, California 95982

(530) 822-5155

Parental Permission Form for Athletics

***My child may participate in the following sport during this school year***



please note particular sport

Authorization for Consent to Treatment of Minors

I, the undersigned parent(s) or legal guardian(s) of                                                                                                                       , a minor, do hereby authorize the faculty members of Brittan School, supervising the activity concerned, as agent for the undersigned to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor under general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician, in the exercise of his/her best judgment, may deem advisable.

 Authorization is also given to personnel - authorized by Brittan School - to transport my son/daughter to and from all athletic activities when necessary.




Name of Family Doctor:   Signature of Parent/Guardian:  
Doctor's Phone:   Home Phone:  
    Work Phone:  
Date:   Emergency Numbers: