Authorization for Emergency Medical Treatment. Medical Alert Information (i.e., allergies, medical and/or handicapping conditions): If my child should become ill or be injured under the supervision of the GMS Before/After Care Program, I understand that the staff will contact me immediately. If they are unable to contact me, they will call 911. The medical facility is authorized to administer emergency medical treatment necessary to ensure the health and safety of my child. I will accept responsibility for payment of medical services rendered.
Authorization for Emergency Medical Treatment. This information will be kept in the possession of the parish. A copy will be distributed to the person in charge of each trip or athletic activity in which the student/minor participates. Should the need arise this information will be given to the proper medical authorities.
Authorization for Emergency Medical Treatment. In the event of illness or injury, I hereby authorize MPSC staff with current first aid certification to administer first aid to my child, and I hereby authorize MPSC staff, or other employees or agents of The University of North Carolina at Chapel Hill, to obtain emergency medical treatment for my child at the nearest medical facility as deemed necessary, including administration of an anesthetic or other medication and surgery, and I hereby assume the cost of such treatment. I understand 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 the University and MPSC to give specific consent to the diagnosis, treatment, or hospital care which in the best judgment of a licensed physician is deemed advisable. I understand that MPSC will make best efforts to notify me immediately should emergency treatment for my child become necessary. I also grant permission for emergency CPR to be administered to my child by a certified person should it become necessary.
Authorization for Emergency Medical Treatment. I have listed above my or my child’s physical conditions or medical problems that may need attention and all medications regularly used by myself or said minor. I understand failure to disclose medical information/condition may result in dismissal from Carolina Creek Christian Camp. In case of the illness of myself or my child, Carolina Creek Christian Camp will try to notify whoever is listed as the emergency contact person. In the event there arises a medical emergency concerning myself or my child, at a time where the emergency contact cannot be notified, I authorize Carolina Creek Christian Camp to consent to any necessary X-ray examination, anesthetic, medical or surgical diagnosis or treatment, or hospital care. I hereby consent and give my permission to the Carolina Creek Christian Camp staff or any attending physician to make such decisions and to perform such medical treatments and/or surgery upon myself or my child that may, in their sole discretion, be necessary and proper under the circumstances. General Release and Waiver of Liability I DO RELEASE, ACQUIT, DISCHARGE, AND COVENANT TO HOLD HARMLESS CAROLINA CREEK CHRISTIAN CAMP STAFF, PERSONNEL, OR ANY OF ITS REPRESENTATIVES FROM ANY ACTIONS, DAMAGES, OR LIABILITIES ARISING OUT OF ANY INJURIES OR PROPERTY DAMAGE SUSTAINED DURING THE PARTICIPATION IN THE CAMP AND/OR RESULTING FROM THE TREATMENT OF ANY ILLNESS, SICKNESS, OR ACCIDENT, INCURRED BY MYSELF OR MY CHILD DURING HIS/HER STAY AT CAROLINA CREEK CHRISTIAN CAMP. In consideration for being permitted to attend Carolina Creek Christian Camp and participate in the activities conducted by the Camp, I, on behalf of myself, my child, my legal representatives, heirs and assigns, do hereby release, waive, and forever discharge Carolina Creek Christian Camp and its officers, employees, volunteers, and agents, of and from any and all loss, damage, claim, demand, action or right of action, of whatever kind or nature, either in law or in equity arising from or by reason of any bodily injury or personal injuries known or unknown, death or property damage resulting or to result from any accident that may occur as a result of my or my child’s participation in the camp activities or any activities in connection with the Carolina Creek Christian Camp, whether by negligence or not. I, personally, and on behalf of my child (if child is the camp participant), hereby give Carolina Creek Christian Camp permission to use my and/or my child’s name, photograph, quotat...
Authorization for Emergency Medical Treatment. Athlete Name: The undersigned, legal custodian of A minor hereby authorizes the principle or designee, into whose care the aforementioned minor pupil has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, treatment, and or hospital care to be rendered to said minor upon the advice of any licensed physician and or dentist. This authorization is given by provisions of section 25.8 of the California civil code, and shall remain effective for the full school year unless revoked in writing and delivered to said agents(s). I understand that the Adelanto School District, Its Officers and its employees assume no liability of any nature in relation to the transportation of said minor. I further understand that all cost of paramedic transportation, hospitalization, and any examination, X-ray, or treatment provided in relation to this authorization shall be borne by the undersigned. Doctor/ Hospital Daytime Phone Insurance Company Group # Medication/ Allergies Other Medications Taken Regularly Signature of Guardian: Date: Signature of Guardian: Date: Signature of Guardian: Date: Consent to treat CONSENT TO TREAT/ Activity Waiver This section must be completed WE: and , the parents/guardians of a minor, have entrusted such minor into the hands of The Columbia Middle School for the purpose of taking a school sponsored trip/off campus for the purpose of the Athletic Program and any/all sports my child is participating in. I understand the dates, times and location will be provided by the Coach of any such sport. In connection with such entrustment, we authorize such caring adult(s) to consent to any medical examination, anesthetic, medial or surgical diagnosis or treatment and/or hospital care to be rendered to such minor under the general or special supervision and/or on the advice of any physician and/or surgeon licensed under the provisions of California law in such examination, anesthetic, diagnosis, treatment or hospital care if in another state or country licensed in that state governing the practice of medicine. We further authorize such caring adult(s) to consent to any and all dental examination, dental or surgical diagnosis, treatment, and/or hospital care to be rendered to such minor by any dentist, including but not limited to, any oral surgeon licensed under the provisions of the Dental Practice Act, or if in another state or country licensed under the provisions of law in that state or country governing the prac...
Authorization for Emergency Medical Treatment. I give consent for Transformations staff and its representatives to seek out and sign for the emergency medical care of the above named client. Parent / Legal Guardian Name (if other than client)__________________________________________________________ Address _____________________________________________________________________ Home phone # _________________________ Cell Phone # ___________________________ Emergency phone # _____________________ Work Phone #__________________________ I give consent for the following person to be contacted in the event of an emergency: Emergency Contact Person _____________________________________________________ Address ________________________________________ Relationship to client __________ Phone Numbers ______________________________________________________________ I understand that reasonable effort will be made to contact the guardian and then the emergency contact person at the above phone numbers. If the client is considered to be in immediate danger and requiring medical care, I give consent for emergency medical care. I do not hold Transformations LLC or its representatives liable for any injury or expense incurred in providing and securing medical care. Health Information Allergies____________________________________________________________________________________________________________________________________________________ Medical Problems ____________________________________________________________________________________________________________________________________________________________ Medications/Doseage____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Does the Client have a Living Will? ___ yes ___ no. If yes, Transformations requests a copy of the will be kept on file. If no, Transformations will assist you in obtaining information on setting up a living will at your request. ____________________________________ _____________________________________ Signature of parent/guardian/ or client date Witness Signature date Transportation Form Client Name __________________________________________________________________ Address _____________________________________________________________________ I hereby authorize _________________________________________ to transport the following persons: ________________________________________ ____...
Authorization for Emergency Medical Treatment. Parents authorize the School and its representatives to administer first aid and/or take whatever action deemed reasonable and necessary to preserve the Student’s health and safety, including but not limited to, transporting the Student or having the Student transported to a medical facility, obtaining emergency medical treatment, and authorizing treatment deemed necessary by medical personnel in case of an emergency. Parents agree to reimburse and indemnify the School and its agents for any costs and expenses incurred in securing such medical services for the Student. Parents represent that all medical problems which might affect Student’s participation in the Interscholastic Athletics have been fully disclosed in the Student’s current Emergency and Medical Information Form and understand that it is the Parents’ responsibility to update the Emergency and Medical Information Form as needed.
Authorization for Emergency Medical Treatment. The parents / guardians of the Player grant permission to the Crush Tidal Waves Fastpitch (“CTW”) and its head coaches and their representatives to authorize emergency medical treatment considered necessary by qualified medical personnel for the Player. It is understood that every effort will be made to contact the parents immediately when an emergency occurs. (Waiver and Release) The parents / guardians of the Player do hereby waive and release, to the fullest extent permitted by law, all claims, demands, actions, and rights of action of whatsoever kind, nature, or description which may hereafter arise against CTW and each and every individual associated therewith, including but not limited to its directors, officers, coordinators, coaches, game officials, and scorekeepers, on account of the Player’s participation in the youth softball program sponsored by CTW. The parents / guardians of the Player understand and agree that this waiver and release is intended to cover, and does cover, all actions, causes of action, claims, and demands for, upon, or by reason of any damage, loss, or injury which may be traced either directly or indirectly to the Player’s participation in the program no matter how remote. The parents / guardians of the Player understand that no physical examination is required as a prerequisite to participation in the program; however, a physical exam is recommended. The parents / guardians of the Player hereby certify the parents / guardians of the Player have read the foregoing waiver and release and know and understand its meaning and contents and are executing this Player Parent Agreement as a free and voluntary act for all uses and purposes. Please note the following existing medical conditions and medications for the Player: My daughter has the following limitations and takes the following medications: I hereby certify that I have read the foregoing waiver and know and understand its meaning and contents and have executed it as my free and voluntary act and deed for all the uses and purposes set herein.
Authorization for Emergency Medical Treatment. This form must be completed for each youth under the age of 21 attending the NAACP Convention. Please return the completed form to NAACP Youth & College Division, 4805 Mt. Xxxx Xxxxx, Xxxxxxxxx, XX 00000, email Xxxxxx@xxxxxxxx.xxx or via fax (000) 000-0000. The undersigned parent(s) and or guardian (s) of the following named minor: (Fill in your participating youth’s name) (Fill in name of Youth Unit) has been advised that (youth’s name) is a participant in the Annual Convention to be held by the National Association for the Advancement for Colored People (NAACP) in Houston, Texas. The undersigned herewith consent(s) and approve for the aforesaid minor to attend the Convention. Consent and approval is also granted to the NAACP members and volunteers under whose custody the said minor has been entrusted in loco parentis to authorize and take emergency actions in the case of a medical emergency, such as an accident or sudden illness, on behalf of said minor. Name of Medical Insurer/Provider: Insured I.D. Number and Name: Basic Critical Information on Child’s Medical History/Problems: Special Medications and Medical Problems: Allergies or Other Ongoing Problems: Name and Telephone Number of Child’s Physician/Medical Provider: NAME: D.O.B: ADDRESS: CITY: STATE: ZIP: PHONE NUMBER: EMAIL: ON PENALTY OF PERJURY: Parent/Guardian Signature Advisor Signature Minor Child/Participant NAACP Staff Signature YOUTH ADVISOR CODE OF CONDUCT This form must be completed by each Youth Advisor and Co-Advisor attending the NAACP Convention. Please return the completed form to NAACP Youth & College Division, 4805 Mt. Xxxx Xxxxx, Xxxxxxxxx, XX 00000, email Xxxxxx@xxxxxxxx.xxx or via fax (000) 000-0000. The following is a list of guidelines that each Advisor(s) and Co-Advisor(s) must abide by during the 103rd NAACP Annual Convention: Advisors acknowledge that the NAACP has a zero tolerance policy regarding behavior that is deemed inappropriate; resulting in immediate dismissal of said youth member from the convention at the cost of the said youth’s parents or guardians. Advisors must ensure that each member of the Youth Unit has their name badge on at all times. (Students without name badges will be denied admittance to youth activities and will be sent to the Advisor immediately.) Advisors must attend every youth social event or the members of their respective Youth Unit will be denied admittance into the social. (Advisors and Co-Advisors may alternate in shifts.) Advisors...
Authorization for Emergency Medical Treatment. Junior Sailor: Date of Birth: Club: Watch Hill Yacht Club Local Address: Parent or Guardian: name relationship home phone business phone name relationship home phone business phone Chronic illnesses, medical conditions, allergies, or medication being taken please list, or _ “X” if none: Latest Tetnaus Shot Physician: _Phone ( ) Insurance Co. Pol # I hereby authorize an instructor from my Club or Program or an adult who bears this document to authorize emergency treatment for the Junior Sailor in the event that a parent or legal guardian cannot be reached at the above telephone numbers at the time of the emergency.
