AUTHORIZATION FOR MEDICAL CARE. I understand that my child is voluntarily participating in a program being held at Valdosta State University. By signing this form I hereby acknowledge that all information is accurate and current, that any activity restrictions, allergies, and medications are listed on this form, and to the best of my knowledge, my child is capable of participating safely in the program. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in my child’s mental, physical, or medical condition before the program begins. I understand that Valdosta State University does NOT provide medical insurance for my child and that I should consult my child’s physician before allowing my child to participate in this program. In the case of accident or illness, I hereby authorize the program staff to administer or seek medical treatment for my child, as they see fit, including routine first aid care or emergency medical treatment. I hold harmless and agree to indemnify the program, Valdosta State University and the Board of Regents from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment. I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage sustained through my child’s participation in such voluntary program.
AUTHORIZATION FOR MEDICAL CARE. In case of emergency, the senior and the parent/guardian of the senior named below authorize all medical, surgical, diagnostic, and hospital procedures as may be deemed necessary and performed by a treating health care provider. USE OF LIKENESS: Senior and parent/guardian give full consent to Grad Nights to make and use photographs, videos, or likeness of any senior attending this event for the purpose of advertising, publicizing, promoting, etc. Additional important provisions and signature lines are on the reverse side of this document. Please read all the terms of this agreement, provide the information requested in the contact information section below, and sign the reverse side of this form acknowledging your agreement to all terms set forth on both sides of this document. CONTACT INFORMATION Senior Name: Date of Birth: Senior Cell Phone: Senior Email: Address: Parent/Guardian Name(s): Parent/Guardian Phone(s): Parent/Guardian Email: Emergency Contact Name: Relationship to Student: Phone Number(s) Medications: Chronic Illnesses/Allergies: Date of Last Tetanus Shot: Insurance Provider: Does your senior have a life-threatening food allergy? □ NO □ YES – You will also need to complete, at a later date, an Emergency Care Plan (“ECP”). The Parent Planning Committee will have ECPs available. The signature page (next page) must be attached or printed on the back side of this form. All information contained herein is strictly confidential, protected by copyright and intended for use only by the 2017 committee. Use of this form, or any part or derivation by any committee, group or individual not currently working with Grad Nights is strictly prohibited.
AUTHORIZATION FOR MEDICAL CARE. Unless prior arrangements have been made, medical needs will be handled through the nearest hospital. If traveling off campus, Youth Program Staff will select qualified facility. In cases where medical attention is necessary, parents will be contacted for approval when possible. However, before medical treatment can be provided, we are required to have a medical release signed by the parent. Medical facilities will not perform services unless this signed medical release form. (Youth Participant Name) has my permission to receive medical attention in the event of illness or medical emergency while participating in this UTRGV Youth program. I will assume financial responsibility for any cost of health care that may occur during this Youth program.
AUTHORIZATION FOR MEDICAL CARE. I consent to and authorize GRA to administer or obtain medical care for me and/or the Minor Participant in the event of an injury, illness or accident requiring medical attention. I further consent to the release of any and all personal health information of mine, or the Minor Participant to third parties reasonably necessary for the provision of medical care. I accept sole financial responsibility for any hospital, medical or other costs arising out of an injury or other loss arising from or relating to my or the Minor Participant's enrollment or participation the Activities; including evacuation, and medical treatment.
AUTHORIZATION FOR MEDICAL CARE. In case of medical emergency, I hereby authorize any medical treatment deemed necessary. I give Pure Baja Travels permission to hospitalize, secure proper treatment for, and/or to order injection, anesthesia, or surgery for myself and/or the minor named herein.
AUTHORIZATION FOR MEDICAL CARE. Unless prior arrangements have been made, medical needs will be handled through the Peach County Regional Medical Center. In cases where medical attention is necessary, parents will be contacted for approval when possible. However, before medical treatment can be provided, we are required to have a medical release signed by the parent/guardian. The hospital will not perform services unless this form is presented at the time of treatment. Participant has my permission to receive medical attention in the event of illness or medical emergency while participating in this Program. I will assume the financial responsibility for any cost of health care for my child that may occur during this Program. As a participant, parent, or guardian I understand and acknowledge that my failure to disclose relevant information may result in harm to Participant and/or others during this Program. By signing my name I represent and warrant that I have provided all materials and important information to Fort Valley State University pertaining to my Participant’s medical, mental and physical condition and that it is accurate and complete. I agree to notify Fort Valley State University of any changes in my mental, physical or medical condition prior Participant’s scheduled Program. By revealing or disclosing the above medical information it will not be used by Fort Valley State University personnel or employees to determine Participant’s ability to participate safely in activities. I understand that, if Participant chooses to participate in activities, he/she do so voluntarily and of his/her own accord and the final decision regarding participation is solely the responsibility of myself and Participant. Participant’s Name: Print Name Signature Date Parent/Legal Guardian Name: Print Name Signature Date PLEASE NOTE: A Parent/Legal Guardian must sign this form for a minor under the age of 18. Only the enrolling parent will be permitted to complete this form. FORT VALLEY STATE UNIVERSITY PROGRAMS SERVING NON-STUDENT MINORS PARENT/GUARDIAN AUTHORIZATION, WAIVER AND CONSENT FOR SELF-ADMINISTRATION OF PRESCRIPTION MEDICATION FORM PROGRAM/CAMP INFORMATION: Program/Camp Name: _ Date(s): Time(s): Location: PARTICIPANT INFORMATION: Name of Participant: Gender: Date of Birth: Phone Number: Address: City: State: Zip: Parent/Legal Guardian Home Phone Cell Phone Parent/Legal Guardian Address (if different from above) This form must be completed fully in order for participants to self-administer r...
AUTHORIZATION FOR MEDICAL CARE. If it becomes necessary for my child to have medical care while participating in this activity, I hereby give school personnel permission to use their judgment in obtaining medical care for the child, and I give permission to the physician selected by school personnel to render medical care deemed necessary and appropriate by the physician. I understand that the school Student Name: Home Address: Parent/Guardian Home Phone No.: Parent/Guardian Work Phone No.: Emergency Contact Phone No.: X Authorized Signature of Parent or Guardian carries student accidental injury insurance in an amount limited to $50,000 (applies excess of family health insurance if applicable.) Parent or Guardian’s Name (please print) Date: PLEASE CHECK HERE IF INSTRUCTIONS FOR SPECIAL MEDICAL TREATMENT AND/OR OVER-THE- COUNTER MEDICATION FOR THE STUDENT ARE ON FILE IN THE SCHOOL. Rev. 7/2017 GVA STUDENT ATHLETE CODE OF CONDUCT The following expectations are for all players and parents.
AUTHORIZATION FOR MEDICAL CARE. In case of emergency, the senior and the parent/guardian of the senior named below authorize all medical, surgical, diagnostic, and hospital procedures as may be deemed necessary and performed by a treating health care provider. USE OF LIKENESS: Senior and parent/guardian give full consent to Grad Nights to make and use photographs, videos, or likeness of any senior attending this event for the purpose of advertising, publicizing, promoting, etc. Contact Information Senior Name: Date of Birth: Senior Cell Phone: Senior Email: Address: Parent/Guardian Name(s): Parent/Guardian Phone(s): Parent/Guardian Email: Emergency Contact Name: Relationship to Student: Phone Number(s) Does Senior have a life -threatening allergy or condition ? Y–ou< wi(ll a6lso need to complete, at a later G D W H D Q · ( P H Planning Committee will have ECPs available. Due to the types of venues where events are held, custom meals for special dietary needs cannot be guaranteed available, or that there are no cross- contamination issues in the commercial kitchens. If you have any special dietary needs, you will be responsible for providing your own food notify the party chairperson of your special needs and that you will provide your own meal. p–lease The signature page (next page) must be attached or printed on the back side of this form . This form is the property of Grad Nights and must be returned to Grad Nights the night of the party. All information contained herein is strictly confidential, protected by copyright and intended for use only by the 2020 committee. Use of this form, or any part or derivation by any committee, group or individual not currently working with Grad Nights is strictly prohibited. ' 1983 -2019 Grad Nights. Grad Nightsfi is a registered trademark of The Xxxxxx Group, Inc. Important Additional Provisions
AUTHORIZATION FOR MEDICAL CARE. I give permission to Program/Event staff to provide routine first aid care and in the event of serious illness or injury, I give Program/Event staff permission to seek and authorize emergency medical treatment. I hold harmless and agree to indemnify the Program/Event and the University of Michigan from any claims, causes of action, damages and/or liabilities arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my child that may occur during his/her participation in this Program/event. Parent/Guardian Initial
AUTHORIZATION FOR MEDICAL CARE. The Student authorizes the College and its officers and employees to authorize emergency transportation and/or medical care as may be considered necessary or appropriate. The College and its officers and employees shall not be responsible in any way for any consequences resulting from said transportation and/or medical care and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incidental to such transportation and/or medical care insofar as the law allows. The student may provide and authorizes the college to contact emergency contacts given in such situations resulting in medical transport or hospitalization. Missing Persons Policy Umpqua Community College is authorized to enact procedures, as appropriate and permitted by law, regarding the notification of missing students. Every student who resides in UCC’s housing facilities are encouraged to identify an individual who will be contacted by the College in the event that the student is determined missing. Access to this information will be available only to professional staff of the Housing Department, along with the Student Conduct office and Campus Security. For more information on this policy and to submit your emergency contact information, please follow the link to UCC’s Missing Persons Policy Policies and Expectations Standards of Student Conduct All members of the College are responsible for obeying the rules, which are essential for preserving an environment conducive to academic pursuits, as outlined in the Student Code of Conduct.
