CONSENT FOR EMERGENCY MEDICAL TREATMENT. We, the Parents of , give permission for emergency medical treatment of our child for illness or accident if we cannot first be contacted. Emergency Parent or Guardian: Name: Phone: Office: Mobile: Email: Emergency Secondary Contact: (other than parent) Name: Phone: Office: Mobile: Email: Relationship: Does your child have any allergies or require special medication: Yes: No: Explanation: Signature (Parent/Guardian) Date Hold Harmless Statement WE HEREBY AGREE THAT THE SOCCER ASSOCIATION FOR YOUTH (SAY) ITS MEMBERS, COACHES OR OFFICERS SHALL NOT BE LIABLE FOR ANY INJURY OR LOSS IN WHICH MY CHILD MAY SUSTAIN WHILE PARTICIPATING IN ACTIVITIES OF ANY KIND WHETHER SPONSORED BY OR UNDER THE SUPERVISION OF SAY AND WE AGREE TO IDEMNIFY AND TO HOLD HARMLESS SAY, IT’S MEMBERS, COACHES AND OFFICERS OR DESIGNATES OF ANY KIND FROM ANY CLAIM WHATSOEVER. Signature (Parent/Guardian) Date This statement CANNOT be altered to include your District, SAYArea, SAY Organization, City, etc. If you need an additional statement that includes any other entity, then simply add another statement beneath this statement on your player registration form, electronic registration form, etc. Our insurance carrier dictates this.
CONSENT FOR EMERGENCY MEDICAL TREATMENT. In cases of emergency, the Shenandoah Academy of Dance is authorized to arrange for medical services for the student and I consent to appropriate medical and surgical service recommended by licensed medical pro- fessionals. I accept full responsibility for all costs of said medical care and any emergency treatments. The Shenandoah Academy of Dance will not be responsible for the cost of any medical care or emergency treat- ments. I hereby waive all claims whatsoever in connection with such medical treatments. I agree that Shenan- doah Academy of Dance including its instructors will not be held liable for and agree to hold Shenandoah Academy of Dance including its instructors harmless from any and all liabilities, losses, damages or expenses related to the student’s participation in any activities at Shenandoah Academy of Dance. I have read and agree to the 2020 – 2021 Consent for Emergency Treatment. Signed: Parent / Legal Guardian / Adult Student Payor Date: I have read the above waiver and sign it voluntarily. I agree to adhere to these policies to ensure the safety of my children and the integrity and professional atmosphere of the Shenandoah Academy of Dance. I, (Xxxxxx’s/Guardian’s Name), hereby represent to the Shenandoah Academy of Dance that my child is of sound health and has no history of a medical or physical condition which could in any shape, manner or form place my child at risk because of said condition. I acknowledge that I have been informed by the Shenandoah Academy of Dance of the nature of the instruction my child will receive and that such instruction involves physical exercise, exertion and stress, which could result in injury and /or disability. Name of Student: Date: Printed Name of Parent/Guardian: Address of Parent/Guardian: Signature of Parent: Cell Phone #: Home Phone #: E-mail Address: Any medical conditions or allergies we should be aware of? No Please Explain: Yes New policy additions Adapted for the 2019—2020 Season Stealing / Lying and other serious student misconduct: Stealing on any Shenandoah Academy of Dance or Shenandoah Ballet venue (including but not limited to: the studio or any performance venue), is grounds for dismissal. I am in the position of not just teach- ing ballet steps for my students. It is also my job to instill in my students a sense of community and be- longing as well as integrity, ethics and strong moral fortitude. I will NOT tolerate stealing. (Intl) Lying and other verbally disparaging remarks abo...
CONSENT FOR EMERGENCY MEDICAL TREATMENT. I do hereby give authority to Smart Stars Academy staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. Signature Date / /
CONSENT FOR EMERGENCY MEDICAL TREATMENT. 11. In the event of illness or injury, I hereby authorize University employees to obtain emergency or other medical treatment for me 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 employee to give specific consent to the diagnosis, treatment or hospital care which in the best judgment of a licensed physician is deemed advisable. A copy of this Agreement and Release and Consent for Emergency Medical Treatment shall have the same force and effect as the original. If the High School Student is a minor (younger than 18), one of the High School Student’s parents (or legal guardians) must also signed this High School Student Laboratory Worker Agreement and Release and Consent for Emergency Medical Treatment, and all references to “I,” “me,” “my,” and similar terms shall be read to include both the parent, or legal guardian, and the High School Student. This release and agreement is binding on myself, my heirs, assigns, and personal representatives. Name of HS Student (Print or type) D/O/B Signature of HS Student Date Name of Parent or Legal Guardian (Print or Medical Insurance Information: type) Signature of Parent or Legal Guardian Date
CONSENT FOR EMERGENCY MEDICAL TREATMENT. I do hereby give authority to Stargazer Day Camp Program staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. Parent/Guardian Signature: Date Tel.
CONSENT FOR EMERGENCY MEDICAL TREATMENT. 11. In the event of illness or injury, I hereby authorize University employees to obtain emergency or other medical treatment for me as deemed necessary 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 employee to give specific consent to the diagnosis, treatment or hospital care which in the best judgment of a licensed physician is deemed advisable. A copy of this Agreement and Release and Consent for Emergency Medical Treatment shall have the same force and effect as the original. If the Student is a minor (younger than 14), one of the Student’s parents (or legal guardians) must also signed this Laboratory / Shop Agreement and Release and Consent for Emergency Medical Treatment, and all references to “I,” “me,” “my,” and similar terms shall be read to include both the parent, or legal guardian, and the Student (Minor). This release and agreement is binding on myself, my heirs, assigns, and personal representatives. Name of Minor (Print or type) D/O/B Signature of Minor Date
CONSENT FOR EMERGENCY MEDICAL TREATMENT. I, , and if applicable the parent/legal guardian (Please Print) (Please Print) Give permission to the officials of Swim Ontario to make decisions concerning medical care and treatment, and where necessary to authorize such care and treatment in emergency situations. I understand that the officials of Swim Ontario will make every reasonable effort, in the circumstances, to contact the Emergency Contacts regarding my or my child’s/xxxx’x medical status in the event an emergency arises. In the event that the Emergency Contact cannot be reached in an emergency, I hereby give my permission to the licensed physician, dentist, athletic therapist, nurse or other medical professional, whose services might be required, to provide medical care and treatment. By signing here, I indicate that I have the understanding and capacity to communicate health care directives for my child/xxxx, and that I am fully informed as to the contents of this document. Dated: , 20 _ Signature Dated: , 20 _ Parent/Guardian Photograph/Video Consent Form In consideration of my engagement as a registrant of Swim Ontario, and for other good valuable consideration herein acknowledge as received, I hereby grant to Swim Ontario – its staff, Board Representatives, and those acting with its authority and permission, the irrevocable and unrestricted right and permission to take, copyright in their own name and otherwise, and use, reuse, and publish pictures of me in all artwork or media used in promotion, editorial, trade, advertising, Broadcast/live streaming of events, website display, social media, or for any other purpose whatsoever. I also consent to the use of any published matter in conjunction therewith. I hereby release, discharge and agree to save harmless Swim Ontario – its staff, Board Representatives, and those acting with its authority and permission, from any liability of distortion or altered use that may occur or be produced in the taking of said picture(s), video, or in any subsequent procession thereof, including without limitation any claims for libel or invasion of privacy. I hereby warrant that I am of full age or have a Parent/Guardian to rightly contract my own name. I have read the above authorization, release and agreement, and I am fully familiar with the contents thereof. This release shall be binding upon me and my heirs, legal representatives, and assigns. NAME: DATE: SIGNED: Parent/Guardian: SIGNED: Participant (if 18 years of age or older: WITNESS: SWIM ONTARIO SOCIA...
CONSENT FOR EMERGENCY MEDICAL TREATMENT. 9. In the event of my illness or injury, JSNN employees are authorized to call medical emergency services for emergency assistance or other medical treatment for me as deemed necessary. Because I am a minor, and am not of legal age, my parent or legal guardian, who has legal responsibility for me, must also sign a Parent/Legal Guardian Agreement, Release and Consent for Emergency Medical Treatment in Connection with Activities in Research Labs. My parent/legal guardian also must also sign this agreement to acknowledge my commitment to the conditions I have agreed to meet. ______________________________________________ ____________________ Name of Minor Participant (print or type) Date ___________________________________________________ Signature of Minor Participant __________________________________________________ _________________ Name of Minor’s Parent or Legal Guardian (print or type) Date _________________________________________________ Signature of Minor’s Parent or Legal Guardian ___________________________________________________________ ________ Name of Witness (print or type) Date __________________________ _________________________ Signature of Witness Minor’s Medical Insurance Information (Name of Carrier and Policy Number):
CONSENT FOR EMERGENCY MEDICAL TREATMENT. 10. In the event of illness or injury, I hereby authorize JSNN employees to call medical emergency services for emergency assistance for my child/xxxx 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 JSNN employee to give specific consent to the diagnosis, treatment or hospital care which in the best judgment of a licensed physician is deemed advisable. A copy of this Agreement and Release and Consent for Emergency Medical Treatment shall have the same force and effect as the original. My minor child/xxxx must also sign a Minor Agreement in Connection with Activities in Research Labs to recognize and acknowledge his/her roles and responsibilities in this Agreement. My child must also sign this document to acknowledge their awareness of my roles and responsibilities in this Agreement. This release and agreement is binding on me, my heirs, assigns, and personal representatives.* _______________________________________________________ _________________ Name of Minor Participant (print or type) Date ____________________________________________________ Signature of Minor Participant _________________________ __________ _____________________________________ Name of Minor’s Parent or Legal Guardian (print or type) Date ___________________________________________________ Signature of Minor’s Parent or Legal Guardian ___________________________________________________________ __________________ Name of Witness (print or type) Date ______________________________________________________ Signature of Witness Minor’s Medical Insurance Information (Name of Carrier and Policy Number): ____________________________________________________________________
CONSENT FOR EMERGENCY MEDICAL TREATMENT. I hereby give my consent to Splash Swim School, and/or its officers, directors, shareholders, employees, and/or agents, to obtain all emergency medical or dental care prescribed by a duly licensed physician or dentist for the Child. In the event that the Child receives any treatment authorized by this consent, I will promptly reimburse Splash Swim School, and/or its officers, directors, shareholders, employees, or agents in the event that it and/or they incur costs relating to any such treatment provided to the Child.
