Common use of AUTHORIZATION FOR MEDICAL CARE Clause in Contracts

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. 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 2019 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. 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 Senior have a life-threatening food allergyallergy or condition? □ 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. 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 – please notify the party chairperson of your special needs and that you will provide your own meal. 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. 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 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: Phone Number(s) 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 2019 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.