EMERGENCY MEDICAL AUTHORIZATION. I give permission for emergency medical/dental treatment or first aid to be administered to my child for any illness/injury/accident resulting from participation in Pop Warner activities.
EMERGENCY MEDICAL AUTHORIZATION. I hereby authorize any medical treatment deemed necessary in the event of any injury while participating in the Events. I have appropriate insurance, or in its absence, agree to pay all costs of rescue and/or medical services as may be incurred on my behalf.
EMERGENCY MEDICAL AUTHORIZATION. Student and Parent hereby request, authorize and give full permission and consent to the Envision Parties to act on behalf of Student and Parent and in their stead should Student become ill, be injured or require emergency or other medical treatment, including hospitalization and/or surgery, during the Program. Student and Parent further authorize Envision to contact Xxxxxx and Student’s emergency contact(s) and discuss the nature of Student’s illness or injury with such emergency contact(s). Student and Parent understand and agree that in the event of such illness or injury, Student will, if it appears necessary in the judgement of Envision Parties, be taken to an urgent care facility or a hospital emergency room and examined by physician and/or other medical professional. If the physician or medical professional determines that Student does not require hospitalization but should not continue as a Program participant, at the written direction of the physician or medical professional, Student may either be sent home promptly, or Envision will consult with the family on options for the participant until such time as a physician or other medical professional determines that Student is able to safely travel home or rejoin the Program activities. In the event of a reportable communicable disease, as defined by the applicable state’s Board of Health or if a physician or medical professional advises that the Student may not rejoin the Program, Parent is responsible for retrieving Student from the Program or to arrange for Student’s safe travel home, at Parent’s expense, within 24 hours. When deciding upon, consenting to or declining medical treatment, Student and Parent understand and agree that the Envision Parties will use reasonable judgment under the circumstances and will defer to the expertise of any medical practitioner who provides services to Student. Other than covered expenses for emergency medical care included within the Tuition, or covered by any supplemental coverage purchased under Student’s Tuition and Travel Protection Plan, as applicable, Student and/or Parent agree to be solely responsible for all expenses incurred as a result of any accident, illness and/or injury suffered by Student and to reimburse the Envision Parties for such expenses paid by Envision. Student and Parent hereby release and agree to hold harmless the Envision Parties from all claims, demands, damages, expenses, whether known or unknown, resulting from, arising out of, or ...
EMERGENCY MEDICAL AUTHORIZATION. In the event of a medical emergency, I hereby consent to the provision of medical treatment deemed necessary or advisable if Sailor is injured or requires medical attention during participation in the Activity. I understand that effort will be made to contact the undersigned/emergency contact prior to rendering treatment to Sailor, but that medical treatment will not be withheld if I/emergency contact cannot be reached. I understand and agree that I am solely responsible for all costs related to such medical treatment and any related medical transportation and/or evacuation. I hereby release, forever discharge, and hold harmless the Sailing Club from any claim based on such treatment or other medical services. Publicity Release. Sailing Club desires to use and publicize the name, likeness, and other personal characteristics and private information of Sailor for advertising, promotion, and other commercial purposes. I hereby irrevocably permit, authorize, grant, and license Sailing Club and its licensees and agents, and the employees, officers, directors, members, agents, successors and assigns of each of them ("Authorized Persons"), the rights to display, publicly perform, exhibit, transmit, broadcast, reproduce, record, photograph, digitize, modify, alter, edit, adapt, create derivative works, exploit, sell, rent, license, otherwise use, and permit others to use Sailor’s name, image, likeness, appearance, voice, biographical information, signature, other personal characteristics and information in materials created by or on behalf of Sailing Club that incorporate any of the foregoing ("Materials") in perpetuity, worldwide, in any medium or format whatsoever, now existing or hereafter created, on any platform and for any purpose, without further consent from or royalty, payment, or other compensation. I acknowledge and agree that I have no right to review or approve Materials before they are used by Sailing Club, and that Sailing Club has no liability to Sailor for any editing or alteration of the Materials or for any distortion or other effects resulting from Sailing Club's editing, alteration, or use of the Materials, or Sailing Club's presentation of Sailor. Any credit or other acknowledgment of Sailor, if any, shall be determined by Sailing Club in Sailing Club's sole discretion. To the fullest extent permitted by applicable law, I hereby expressly and irrevocably waive and release any and all claims, now or hereafter known, against the Sailing Club an...
EMERGENCY MEDICAL AUTHORIZATION. I, the undersigned, do hereby authorize Xxxxxxx State University and its agents or representatives to consent, on my behalf, to any medical/hospital care or treatment (including locations outside the U.S.) 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. The effective dates of this authorization are to . I am eighteen (18) years of age or older, have read the above authorization, and confirm that the information contained therein is true and accurate. (*If the participant is not eighteen (18) years of age or older, this release must be signed also by a parent/guardian.) Date: (Signature of Individual)
EMERGENCY MEDICAL AUTHORIZATION. I hereby give permission for the staff of the Merrimack Valley YMCA, to provide basic first aid and/or CPR/AED treatment to my child, , when necessary. In the event of a more serious illness or injury, I give permission for my child to be transported to a hospital or other emergency medical facility to receive emergency medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary, and I authorize licensed health practitioners working in the hospital or emergency medical facility to examine and provide emergency medical treatment to my child if warranted. I understand that YMCA personnel will make every effort to contact me regarding any emergency involving my child. / / Parent/Guardian Signature Date Medical Information Child’s Physician: Phone #: Physician’s Address:
EMERGENCY MEDICAL AUTHORIZATION. (Parent/Guardian please complete) My child has the following medical conditions, which may require special attention: Authorization Signature of Parent/Guardian Allergies (list) Print Name of Parent/Guardian Diabetes Seizures Other (Explain) Please provide 2 telephone numbers for emergency contact. My child will need medication while on this trip*: Yes □ *If “Yes,” the authorization must be on file in the UHS Office. No Contact Name / Telephone Number Please check here if special instructions regarding medical treatment are on file in the UHS Office. Contact Name / Telephone Number Student Telephone Number NOTE: This form must be completed for participating in all field trips conducted by University High School within the State of California.
EMERGENCY MEDICAL AUTHORIZATION. The parent/guardian shall execute an Emergency Medical Authorization form which will enable the Producer to obtain necessary emergency medical treatment for the Minor.
EMERGENCY MEDICAL AUTHORIZATION. I authorize to obtain immediate consent and care to (Family Day Care Provider’s Name) emergency medical procedures upon, the hospitalization of, the performance of necessary diagnosis tests upon, the use of surgery on, and/or the administration of drugs to if an emergency occurs and I cannot be located immediately. (Child’s Name) I further understand that this agreement covers only those situations which are true emergencies and only when I cannot be reached. Physician / Clinic: Address: Hospital: PARENT’S SIGNATURE DATE Name of Insurance Company / Medicaid: Address: Telephone: ( ) Policy / Medicaid Number: Child Care Services Office Sample Form CCS019
EMERGENCY MEDICAL AUTHORIZATION. I, the undersigned, do hereby authorize Xxx Houston State University and its agents or representatives to consent, on my behalf, to any medical/hospital care or treatment (including locations outside the U.S.) 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. The effective dates of this authorization are August 23, 2019 to May 31, 20 19 . I am eighteen years of age or older, have read the above authorization, and confirm that the information contained therein is true and accurate. Date 20 19 . (Signature of Individual Providing Authorization)
