CONSENT FOR MEDICAL TREATMENT. I HEREBY give my consent for emergency medical care provided by a Doctor of Medicine, Doctor of Dentistry or other medical or urgent care personnel. This care may be given under whatever conditions are considered necessary to preserve the life, limb or well-being of Participant.
CONSENT FOR MEDICAL TREATMENT. This is to certify that on this date I, , give my consent to The Effortless Kitchen, LLC or their representative to obtain medical care from any licensed physician, hospital or clinic for me for any injury or illness that may arise during this activity. In the event of sickness or accidents, I will not hold the activity organizer, its officials, officers, directors, employees, agents, volunteers and assigns responsible. In case of sickness or accident, I authorize the calling of a medical doctor and/or providing of other necessary medical services. I agree to pay for those medical services that are deemed necessary by medical authorities. Date: [Participant Name] INSURANCE INFORMATION: Carrier: Policy Holder: Policy/Group Number: EMERGENCY CONTACT(S): Name Relationship Phone Name Relationship Phone PLEASE LIST ANY IMPORTANT MEDICAL CONDITIONS OR ALLERGIES OF WHICH
CONSENT FOR MEDICAL TREATMENT. In the event of illness or injury, I hereby authorize employees or agents of the University to obtain emergency 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 to give specific consent to the diagnosis, treatment, or hospital care which in the best judgment of a licensed physician is deemed advisable. I also grant permission for emergency CPR to be administered to me by a certified person should it become necessary.
CONSENT FOR MEDICAL TREATMENT. If, in the opinion of a properly licensed and practicing physician, the Student needs emergency medical or surgical services which require the Parent's pre‐authorization or consent, the Parent hereby authorizes, appoints, and empowers the School to act as the Parent's lawful representative for the purposes of taking all steps necessary to ensure the proper care of the Student, and to execute any and all necessary documents and papers requested by the licensed and practicing physician prior to treatment of or rendering of care to the Student. The Parent confirms that it is the Parent's desire that the Student be furnished with such medical or surgical services as soon as reasonably possible after the need arises. The Parent hereby releases and holds the School harmless from any liability that might arise from acting as the Parent's lawful representative for the purposes stated herein. The Parent agrees to reimburse the School for any medical expenditure made on the Student's behalf.
CONSENT FOR MEDICAL TREATMENT. I agree that SLCC may, but is not obligated to, make any decisions and take any actions regarding my health, safety, and welfare that it considers to be warranted under the circumstances, and hereby authorize SLCC to make such decisions and take such actions. I agree to pay all expenses relating thereto and release SLCC from any liability for any such actions.
CONSENT FOR MEDICAL TREATMENT. I, the undersigned, am knowingly requesting medical services from Pacific Retina Care℠. I am requesting these services willingly and voluntarily. I execute the same as my free and voluntary act for the purpose of receiving the healthcare services. By my signature below, I warrant that I am eighteen (18) years of age or older, of sound mind, and not constrained nor under any undue influence. I understand that my physician will be responsible for providing me with an explanation of current information regarding my diagnosis, treatment and prognosis and will require my consent on any procedures performed on me. My physician will ensure that I am adequately informed and that I understand the indications of any procedure performed by a Pacific Retina Care℠ physician. I understand that I have the right to refuse such care, except in an emergency. I authorize Pacific Retina Care℠ to disclose/request my health information including copies of records as necessary to/from:
CONSENT FOR MEDICAL TREATMENT. I HEREBY give my consent for emergency medical care provided by a Doctor of Medicine, Doctor of Dentistry or other medical or urgent care personnel. This care may be given under whatever conditions are considered necessary to preserve the life, limb or well-being of Participant. I HEREBY give my consent to use the participants picture and/or name on our website for achievement recognition and promotional reasons. CONCUSSION LAW I UNDERSTAND have I have the concussion and head injury information sheet available to me on the xxxxxxxxxx.xxx website and that I have read the concussion and head injury information sheet. I understand that there is a risk of injury during athletic participation and I agree to disclose any signs and symptoms of a concussion to the camp coaching staff. I also understand that I will be removed from play to eliminate the risk of further injury and will not be able to resume participation until evaluated and cleared by a licensed physician who has experience with evaluating and managing pediatric concussions and head injuries. I understand that this is in accordance with the State of Wisconsin Youth Concussion Law.
CONSENT FOR MEDICAL TREATMENT. As the parent or legal guardian of a participant in the FYBA Programs, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent. Date: Signature of Parent/Legal Guardian: Notes:
CONSENT FOR MEDICAL TREATMENT. In the event of an accident or injury to my Child, authorization is hereby given to an appropriate adult representative or chaperone of Xxxx Avenue Baptist Church to do or arrange for any acts which may be necessary or proper to provide for the health care of the minor child, including, but not limited to, the power; (i) to provide for such health care at any hospital or other institution, or the employing of any physician, dentist, nurse, or other person whose services may be needed for such health care, and (ii) to consent to and authorize any health care, including administration of anesthesia, X-ray examination, performance of operations, and other procedures by physicians, dentists, and other medical personnel except the withholding or withdrawal of life sustaining procedures.
CONSENT FOR MEDICAL TREATMENT. SJU requires all campers to carry insurance. If a serious illness or injury develops, medical and/or hospital care will be given. There is a consent for treatment area in all camp registrations giving permission to the attending health care provider to secure proper treatment for or to hospitalize the camper. Staff members for the activity are not responsible in case of accidental injury or illness. I/we certify that my/our son/daughter is medically fit to participate in camp and grant permission for medical attention if needed during Camp activities. I release Saint John’s University, its employees and its Camp Staff from all claims that may be sustained by my/our son/daughter while participating in the Camp. I/we agree to indemnify Saint John’s University for each claim, which may hereafter be presented by my/our son/daughter as a result of any such injuries. In addition, my/our son/ daughter currently has health insurance coverage. I have read and I understand this document, including the release and hold harmless portions of it. I understand and agree that it is binding on myself, my child, our heirs, assigns, and personal representatives. Parent/Legal Guardian Signature: Printed name: Date: Child’s Name: Child’s Age: Camp Session(s): June 22‐26 July 6‐10 Parent/Guardian’s Name: Phone Number: July 20‐24 _ Aug 3‐7 EMERGENCY CONTACTS: 2 people able to be reached while camp is in session (include yourself if applicable) Name: Relationship to Child: Phone Number: Name: Relationship to Child: Phone Number: HEALTH + SAFETY SURVEY: Allergies and/or dietary restrictions, and associated reactions:
