Emergency Authorization. Each of the Player and his or her parent/legal guardian hereby authorizes an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility and/or doctor of medicine or dentistry or associated personnel (each, a “Provider”) to provide the Player with medical and/or dental assistance and/or treatment and agrees to be financially responsible for the cost of such assistance and/or treatment. Each of the Player and his or her parent/legal guardian hereby authorizes emergency transportation of the Player to a medical treatment facility, should a Provider consider it to be warranted, and agrees to be financially responsible for the cost of such transportation.
Emergency Authorization. Each Participant authorizes a Farm staff member or volunteer, emergency medical technician, medical treatment facility, and/or doctor of medicine or dentistry, or associated personnel (each, a “Provider”) to provide the Participant with medical and/or dental assistance, and/or other treatment and agrees to be financially responsible for the cost of such assistance and/or treatment. Each Participant hereby authorizes emergency transportation of the Participant to a medical treatment facility by ambulance, should a Provider consider it to be warranted, and agrees to be financially responsible for the cost of such transportation.
Emergency Authorization. The undersigned hereby give permission to licensed medical personnel attending to the treatment of the participant to order x-rays, routine tests and treatment. In the event of an emergency, the undersigned also gives permission to the attending physician to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the participant as named on this form.
Emergency Authorization. During the first year student “Amazing Experience,” emergencies may develop at any time, and these emergencies may necessitate medical care, hospitalization, blood transfusions or surgery. If possible, a Western New England University representative or agent will contact parents, guardians or personal physicians prior to such treatment. However, such contact may not be possible, depending on the nature of the emergency. Therefore, by initialing here, you authorize Western New England University, through the Office of First Year Students & Students in Transition, or its representatives or agents, to secure medical treatment, including anesthesia and surgery if needed. Payments for any medical serviced is solely your responsibility and you are responsible for reimbursing Western New England University or its agents for any expenses, which are incurred on account of any treatment for personal injuries. Please initial here to indicate that you have read and fully understand this paragraph:_____.
Emergency Authorization. I hereby give permission for the staff of the Merrimack Valley YMCA, to provide first aid and/or CPR/AED treatment to my child,
Emergency Authorization. I give my consent for the First Aid and CPR certified staff of Washington Play and Learn Program, to administer first aid and CPR to my child and to contact the above-named physician or dentist if my child has a medical emergency. I also give my consent for my child to be transported to the nearest hospital in the event of a medical emergency and I will be responsible for all medical fees. Preferred Medical Facility: Signature of Parent or Guardian: Printed Name: Date: I hereby attest that my child has: • Been legally enrolled to attend Region 12 School District and, prior to school entry, the Health Assessment/ Immunization forms were completed in their entirety by a licensed health care provider. • Current documentation on site at Washington Primary School of current health records in accordance with section 10-206 of Connecticut State Statutes on Health Measures required for School Admission. • Current documentation on site at this facility of current age-appropriate immunizations, immunizations in- progress or exemption from immunizations against diseases, in accordance with section 10-204a of Connecticut State Statutes on Health Measures required for School Admission. I further attest that my child does not have a disability or health care need that requires special care be taken or provided while at the child care program unless otherwise specified below: Child’s Name Date of Birth Signature of Parent/Guardian Printed Name Date
Emergency Authorization. I hereby give permission to the medical personnel selected by the camp director to administer first aid, and to order x-rays, routine tests, and treatment. In the event of an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the Volunteer. This form may be photocopied for use out of camp.
Emergency Authorization a) I understand that my travel may take me to areas where medical care may be limited. I understand that emergencies can occur at any time, and that these emergencies may necessitate medical care, hospitalization, blood transfusion, or surgery. If possible, a University representative or agent will contact my family, spouse, guardian, or other person whose name I have provided in the Xxxxx Abroad Travel Registration System as my emergency contact. It is my responsibility to ensure that powers of attorney are completed prior to my departure.
b) In the event that I am incapacitated, I understand that contacting the individual(s) granted authority by me, or by law, to make medical decisions on my behalf may not be possible. Therefore, I authorize the University to secure medical treatment, including anesthesia and surgery, if deemed necessary by a medical professional. I understand that payment for any medical services is solely my responsibility and I agree to reimburse the University for expenses incurred on account of my injury or treatment. I understand that the University will release my medical information to the medical provider(s) in the event I am unable to do so.
Emergency Authorization. I, the undersigned parent or legal guardian, hereby authorize the designated instructor or official acting as an activity supervisor, as my agent, to seek medical, surgical, or dental examination and treatment in the event of an injury.
Emergency Authorization. I hereby give permission for the staff of the Merrimack Valley YMCA, to provide first aid and/or CPR/AED treatment to my child, Signature of Parent/Guardian: Date: Child’s Physician: Phone #: Physician’s Address: C xxxx’x Dentist: Phone # Dentist’s Address: Insurance Carrier: Policy #: List any chronic conditions, dietary restrictions, or medications: List any allergies, reactions and treatment: Does your child have an IEP (Individualized Education Plan) or a 504 Plan? If yes, please attach: If yes, please attach If yes, please attach I give permission to the YMCA to public my child’s name and photograph in YMCA brochures, newspaper or other publications. Yes No (If yes, Initial: ) I give my permission for my child to attend instructional classes and/or recreational swims at the designated Merrimack Valley YMCA Branch. [Xxxxxxxx/Andover/North Andover Only] Yes No (If yes, Initial: ) I give permission to the Merrimack Valley YMCA Staff to speak and/or exchange documents concerning my child with school personnel. Yes No (If yes, Initial: ) Child’s Name: Eye Color: Hair Color: Skin Color: Height: Weight: Identifying Marks: Primary Language: List any physical limitations or special situations your child has: List any allergies or food intolerance that your child may have: Does your child take medication(s) regularly? Yes No If yes, please list the name of the drug, how often they receive this medication and what time it is to be given. (Please check the parent handbook regarding our policy on dispensing medication during program hours.): List all Holidays, celebrations and occasions that your family celebrates: List your child’s special interests and hobbies: Favorite physical activities: Favorite Game/Toy: Favorite TV Show: Favorite Snack: Favorite Book: Does your child enjoy musical activities? Yes No Does your child primarily use his/her right or left hand? Right Hand Left Hand No Preference Yet By nature is your child: Aggressive Shy Serious Friendly Withdrawn Easy Going How do you reassure your child when he/she is upset? Does your child nap? Yes No How does your child get along with other children? Does your child prefer to play alone or with other children? Do you feel your child will adjust easily? Yes No If no, why? Does your child demand a lot of attention? Is your child the only child in your family? Yes No If no, do they all reside in your home? Yes No Please list siblings & ages: How does your child show: Happiness Anger Disappointment What do you...
