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. I hereby give permission for the staff of the Merrimack Valley YMCA, to provide first aid and/or CPR/AED treatment to my child, , when necessary and 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. Signature of Parent/Guardian: Date: Medical Information Child’s Physician: Phone #: Physician’s Address:
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 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.
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. I understand that I am responsible for covering any medical expenses incurred on account of sickness, because insurance for sickness is not provided by MAI. Travel Insurance MAI recommends that each LittWorld participant purchase travel insurance to cover emergency medical treatment and/or medical evacuation to the closest destination that can provide medical treatment. I understand that travel insurance is voluntary and up to me to arrange and pay for. I agree to indemnify and hold MAI harmless for any damages or other losses sustained as a result of my decision not to purchase travel insurance. I also agree to indemnify and hold MAI harmless from all claims, settlements, judgments and costs, including but not limited to attorneys’ fees, and to reimburse them for any expenses whatsoever incurred in connection with an action brought as a result of my declination to purchase such travel insurance coverage. Participant must sign. X
Emergency Authorization. In the event of an emergency in which I cannot be reached, I authorize U.S. embassies and consulates to release information concerning my welfare and whereabouts to Northwestern University.
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. 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. Participant must sign. Parent/Guardian signature is required for participants under age 18. X Participant: Print Name Signature Date X Parent/Guardian: Print Name Signature Date Notary Certificate of Acknowledgement State of ILLINOIS County of DU PAGE This instrument was acknowledged before me on by . (Date) (Name/s of person/s signing document) (Seal) Signature of Notary Public Medical Insurance I understand that I am responsible for covering any medical expenses incurred on account of sickness, because insurance for sickness is not provided by College Church. My medical insurance provider is: Insurance Company: Address: Policy and/or Group Plan Number: Identification Number of the Insured: Phone The participant is: The insured A covered dependent of the insured If a Covered Dependent, the Name of the Insured is: You must have medical insurance to participate on a short-term trip. Please tape a photocopy of both sides of the medical insurance card that covers the participant in the space below. Participant must sign. Parent/Guardian signature is required for participants under age 18. X Participant: Print Name Signature Date X Parent/Guardian: Print Name Signature Date Notary Certificate of Acknowledgement State of ILLINOIS County of DU PAGE This instrument was acknowledged before me on by . (Date) (Name/s of person/s signing document) (Seal)
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, , when necessary and 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. Signature of Parent/Guardian: Date: 2017-2018 Medical Information 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: Does your child have an Individual Health Plan (for children with a chronic health condition)? If yes, please attach Do you have a custody agreement, court order, and/or restraining order pertaining to the child? If yes, please attach Promotional Release 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: ) 2017-2018 YMCA Developmental History Form 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 tha...
