Common use of Consent for Emergency Treatment Clause in Contracts

Consent for Emergency Treatment. I authorize the University of Wisconsin-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 authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s):

Consent for Emergency Treatment. I authorize the University of Wisconsin-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 authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s)::

Consent for Emergency Treatment. I authorize the University of Wisconsin-Xxxxxxx Point Fond du Lac 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 (if If Participant is Under under 18*): Date: Emergency Contact Information: Name: Address: Phone(s):*If your son, daughter or xxxx will be under 18 while participating in at the University of Wisconsin –

Consent for Emergency Treatment. I authorize the University of Wisconsin-Wisconsin - Xxxxxxx Point Homeconing 5K on 10.21.23 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 (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s):Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin-Wisconsin Xxxxxxx Point at Wausau 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 (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s):Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin-Wisconsin – 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 authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact InformationDate: ------------------------------------------------------------------Administrative Use Below-------------------------------------------------------------------------------- Step 1. Print Name & Date: Staff Name: Address: Phone(s):Date:

Consent for Emergency Treatment. I authorize the University of Wisconsin-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 authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s)::

Consent for Emergency Treatment. I authorize the University of Wisconsin-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 authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s):): *For Office Use Only Belay School Completed: Instructor’s Signature Date:

Consent for Emergency Treatment. I authorize the University of Wisconsin-Xxxxxxx Point Wisconsin­Oshkosh 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. Initial: I understand and agree to the above statements: Signature: Date: Signature of Parent or Guardian (if If Participant is Under under 18*): Date: Emergency Contact Information: Name: Address: Phone(s)::

Consent for Emergency Treatment. I authorize the University of Wisconsin-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 authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s):Guardian