Treatment for Injury or Illness caused by deliberate endangerment of your Pet, such as organized fighting;
Treatment for Injury. I authorize the treatment of the student by a qualified and licensed doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment or undue discomfort if delayed, if said minor is participating in Activities, including transportation to and from the site. This authority is granted only after a reasonable attempt has been made to contact me, the parent/guardian.
Treatment for Injury. I authorize the treatment of the child by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, causing disfigurement, physical impairment, or undue discomfort if delayed, while said minor is participating in the 2021 VBS Program, including transporta- tion to and from the site. This authority is granted only after a reasonable attempt has been made to contact me, the parent/guardian of said minor child.
Treatment for Injury. I, the undersigned, authorize the treatment of the person named above by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her/my life, cause disfigurement, physical impairment, or undue comfort if delayed, while said minor/self is participating in any such Activity, including transportation to and from the site. This authority is granted only after a reasonable attempt has been made to contact me, the parent/legal guardian or self (if 18 years of age or older). Therefore, being the parent, legal guardian, or self (if 18 years of age or older) of the person named above, I give my permission for him/her to attend/participate in all Activities under the DIRECTION AND SUPERVISION OF THE NORTHERN SUSQUEHANNA AREA YOUTH NETWORK AND PARTICIPATING CHURCHES (Also includes ) Insert Church Name SIGNATURE: DATE: NSAYN EVENT - HEALTH FORM DATE: _May 12th 2018 NAME D.O.B. TELEPHONE ADDRESS Name of Family Physician Telephone Health Insurance Co. Policy # Group # Is your teen in general good health? Yes No Presently taking any medication? If so, list what is being taken Please list any limitations on activities Allergies (check any that apply to your teen): Hay Fever _ Convulsions _ Asthma _ Fainting Sulfa _ Poison Ivy (state degree) _ Penicillin Bee Sting Other drug allergies (name) Other allergies If allergic to any of the above, please indicate any medications that your teen is using presently for the stated condition: I certify that the above information is correct, and that my teen has my permission to participate in all NSAYN activities, except as noted above. In case of medical emergency, I understand every effort will be made to contact parents or guardians of the teen. In the event I cannot be reached, I hereby give permission to the physician selected by the NSAYN Event staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my teen, as named there in. Parent or guardian signature Date Should an emergency arise during the NSAYN activity and a parent/guardian is unable to be contacted, give TWO names, addresses and telephone numbers, where persons responsible for the teen may be reached.
