Permission for Treatment definition

Permission for Treatment. The health history provided on this form is correct to the best of my knowledge. By my signature below, I hereby grant permission and authorize the provision of emergency medical treatment in the event of an emergency involving an illness or injury while participating in a visit to the University of Notre Dame.

Permission for Treatment. The health history provided on this form is correct to the best of my knowledge. By my signature below, I hereby grant permission and authorize the provision of emergency medical treatment in the event of an emergency involving an illness or injury while participating in a visit to the University of Notre Dame. I, (we) of , (Parent Name or Guardian) (City) (State) (Country) am the parent(s)/legal guardian(s) of , do hereby state that should an (Name of Child) emergency arise while the above named prospective student is visiting the University of Notre Dame, I, (we) do hereby authorize the University’s staff to obtain emergency medical treatment attention for him/her. I, (we) do hereby give consent to any necessary examination, anesthetic, medical diagnosis, surgery or treatment, and/or hospital care to be rendered under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine during the PROGRAM period. • Family Doctor: Phone: • Family Dentist: Phone: • Medical Insurance: , , (ID Number) (Group Number) (Member’s Name) • Medical History: Allergies, if any, including medication and foods: • Chronic or existing diseases or medical problems (e.g. diabetes, epilepsy): • Medicines now being taken and dosage: • Date of last Tetanus injection or booster (if known): • Any physical restrictions: I, (we) can be reached at the following phone numbers(s) in an emergency: ,( ) (Name and Location) (Phone) ,( ) (Name and Location) (Phone) (Signature(s) of Parent(s)/Legal Guardian(s)) (Date) (Signature of Prospective Student) (Date) We are excited to meet you and hope that after spending a few days with us, you begin to see what it means to be a part of the Notre Dame family. As a Catholic university, Notre Dame has a distinct mission – focused on developing the whole person. Our policies and procedures are intended to contribute to the moral, intellectual, spiritual and social growth of the individuals and groups that constitute this community. As our guests for the weekend, we trust that you will respect all of the policies as outlined by du Lac: A Guide to Student Life, particularly: All students and guests are responsible for complying with University regulations and Indiana laws regarding possession or consumption of alcohol. Any person under 21 years of age is underage in the State of Indiana. All students and guests are expected to comply with Indiana law at all times. Students and guests may be subject to discipl...

Permission for Treatment. The health history provided on this form is correct to the best of my knowledge. By my signature below, I hereby grant permission and authorize the provision of emergency medical treatment in the event of an emergency involving an illness or injury while participating in a visit to Holy Cross College.

Examples of Permission for Treatment in a sentence

• Permission for Treatment, Form 475-0814.b. The “Contractual Agreement,” Form 475-1833.10.6(4) During the interview with the resident finance office, the accounting technician will review the following items with the applicant or legal representative:a.

• A copy of the Permission for Treatment and Liability Release Form must be signed and notarized by every family as part of registration.

• Permission for Treatment and Owner Responsibilities I have read and initialed each topic and I understand and agree to its terms and conditions.

• Receipt of the Privacy Notice will be signed by the client and witnessed by a staff member on the Permission for Treatment (PC-237).

• I attest that I understand and agree to the above provisions and conditions of the Independent Contractor Affiliates Financial Agreement & Permission for Treatment, and I hereby authorize Coastal Counseling Center, P.C. and/or my provider (Independent Contractor associated with CCC), to provide counseling, psychotherapy, and/or medical treatment, for myself or my child by those duly licensed in the Commonwealth of Virginia.