Common use of Consent for Emergency Treatment Clause in Contracts

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin - – Superior and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or GuardianGuardian (if Participant is Under 18):

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Extension and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin – Extension - Superior Ozaukee County and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior – Xxxxxxx Point and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATIONagree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Wisconsin-Madison and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature: Date: Signature of Parent or GuardianGuardian (if Participant is under 18*)

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or GuardianGuardian (if Participant is Under 18): Date: Climbing Wall Rules

Consent for Emergency Treatment. I authorize the University of Wisconsin - – Superior and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Wisconsin-Madison and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or Guardian.

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Kenosha and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Wisconsin-Madison and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or Guardian.

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Milwaukee and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Wisconsin-Madison, the (list other groups) and its their designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATIONagree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian____________________

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATIONagree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Wisconsin-Madison and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Name and Signature of Parent or GuardianGuardian (if Participant is under 18) Name (please print)

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Wisconsin-Madison and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent agree to be responsible for all necessary charges incurred by any hospitalization or Guardiantreatment rendered pursuant to this authorization.

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Superior and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or GuardianGuardian (if Participant is Under 18): Date:

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior – Xxxxxx County and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATIONagree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior   and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior Wisconsin-Madison and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I AGREE TO BE RESPONSIBLE FOR ALL NECESSARY CHARGES INCURRED BY ANY HOSPITALIZATION OR TREATMENT RENDERED PURSUANT TO THIS AUTHORIZATION. Signature: Date: Signature of Parent or GuardianGuardian (if Participant is under 18*)