Common use of Authorization and Consent for Medical Treatment Clause in Contracts

Authorization and Consent for Medical Treatment. I/we the undersigned parent, parents or legal guardian of the above named minor, do hereby authorize in the event of an injury, accident, or illness, ARARAT, its coaches, team representatives, directors, officers, agents, and assignees to seek and obtain care and medical treatment as shall be necessary under the circumstances. I/we hereby authorize and direct the above named to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act, of a dentist licensed under the provisions of the Dental Practice Act, and on the staff of any general hospital holding a current license to operate a hospital from the State Department of Public Health or its equivalent. This authorization is effective whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of my aforementioned agents to give specific consent to any and all such diagnosis which in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned before rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I also agree that this authorization to treat shall be valid in any state where such treatment is rendered. I also agree that if English is not my first language that I have sought out someone to translate this form to me and agree that by my signature that I have read and understood the document. A photocopy of this Authorization will have the effect as the original.

Authorization and Consent for Medical Treatment. I/we the undersigned parent, parents or legal guardian of the above named minor, do hereby authorize in the event of an injury, accident, or illness, ARARAT, California Storm and its coaches, team representatives, directors, officersofficiers, agents, and assignees to seek and obtain care and medical treatment as shall be necessary under the circumstances. I/we hereby authorize and direct the above named to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act, of a dentist licensed under the provisions of the Dental Practice Act, and on the staff of any general hospital holding a current license to operate a hospital from the State Department of Public Health or its equivalent. This authorization is effective whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of my aforementioned agents to give specific consent to any and all such diagnosis which in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned before rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I also agree that this authorization to treat shall be valid in any state where such treatment is rendered. I also agree that if English is not my first language that I have sought out someone to translate this form to me and agree that by my signature that I have read and understood the document. A photocopy of this Authorization will have the effect as the original. Signatures on Page 4. PERMISSION – USE OF NAME AND LIKENESS FOR PUBLICITY AND DISPLAY OF IMAGES ON THE CALIFORNIA STORM WEBSITE AND OTHER MEDIA By participating voluntarily, and on my own accord in the California Storm Basketball Tournament., I hereby grant California Storm, its agents and licensees, and other authorized media including television, radio, and newspapers, unrestricted permission to:

Authorization and Consent for Medical Treatment. I/we , the undersigned parent, parents or legal guardian of the above named minor, do hereby authorize in the event of an injury, accident, or illness, ARARAT, its coaches, team representatives, directors, officers, agents, and assignees to seek and obtain care and medical treatment as shall be necessary under the circumstancescircumstances for my child. I/we I hereby authorize and direct the above named to consent to any have my child be subjected to x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act, of a dentist licensed under the provisions of the Dental Practice Act, and on the staff of any general hospital holding a current license to operate a hospital from the State Department of Public Health or its equivalent. This authorization is effective whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of my aforementioned agents to give specific consent to any and all such diagnosis which in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned before rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I also agree that this authorization to treat shall be valid in any state where such treatment is rendered. I also agree that if English is not my first language that I have sought out someone to translate this form to me and agree that by my signature that I have read and understood the document. A photocopy document and all of this Authorization will have the effect as the originalits words and provisions.

Authorization and Consent for Medical Treatment. IIn the event the Applicant is less than 18 years of age at the time of the anticipated trip, or is otherwise legally incapacitated or disabled (consult counsel if you are unsure of this), it is absolutely necessary for the parent/ guardian to sign this portion of the agreement. If the Applicant is 18 years of age or older and is legally capable, he/ she must sign the consent for medical treatment for himself/we herself. Medical Release for MINOR (17 years of age or younger or otherwise incapacitated or disabled) I hereby give to (name of individual in charge of group) permission to authorize whatever medical treatment may be necessary in the undersigned parentcase of (name of participant) , parents a minor of whom I am the parent or legal guardian of guardian, while on a Yorktown Christian Academy and STCH Ministries mission trip to the above named minor, do hereby authorize in the event of an injury, accident, or illness, ARARAT, its coaches, team representatives, directors, officers, agents, and assignees to seek and obtain care and medical treatment as shall be necessary under the circumstancesDominican Republic. I/we hereby authorize and direct the above named to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act, of a dentist licensed under the provisions of the Dental Practice Act, and on the staff of any general hospital holding a current license to operate a hospital from the State Department of Public Health or its equivalent. This authorization is effective whether If such diagnosis or treatment is rendered at the office of said recommended by a competent physician or dentistsurgeon and is performed by qualified medical personnel, at a hospital, I will not hold (name of individual in charge of group) or elsewhereanyone connected with Yorktown Christian Academy and STCH Ministries responsible in case of adverse results or problems that arise from such treatment. It is understood that this authorization release is valid only in case of an emergency and that a reasonable effort will be made to inform me of the problem and seek my personal decision before taking any action. However, if I cannot be reached, the above named person is given my permission to do whatever is necessary. Signature - Parent/Guardian Date Medical Release for ADULT (18 years of age or older) I hereby give to (name of individual in advance charge of any specific diagnosisgroup) permission to authorize whatever medical treatment may be necessary for me, (name of applicant) , while on a Yorktown Christian Academy and STCH Ministries mission trip to the Dominican Republic. If such treatment is recommended by a competent physician or hospital care being required but surgeon and is given to provide authority performed by qualified medical personnel, I will not hold (name of individual in charge of group) or anyone connected with Yorktown Christian Academy and power on the part STCH Ministries responsible in case of my aforementioned agents to give specific consent to any and all adverse results or problems that arise from such diagnosis which in the exercise of his or her best judgment may deem advisabletreatment. It is understood that effort shall be made to contact the undersigned before rendering treatment to the patient, but this release is valid only in case of an emergency and that any of the above treatment will not be withheld if the undersigned I cannot be reached. I also agree that this authorization consent to treat shall be valid in any state where such my treatment is rendered. I also agree that if English is not my first language that I have sought out someone to translate this form to me and agree that by my signature that I have read and understood the document. A photocopy of this Authorization will have the effect as the originalmyself.

Authorization and Consent for Medical Treatment. I/we the undersigned participant(s) or the parent, parents or legal guardian of the above named minorminor participant, do hereby authorize in the event of an injury, accident, or illness, ARARAT, the KCB and MMTSC its coaches, team representatives, directors, officers, agents, and and/or assignees to seek and obtain care and medical treatment as shall be necessary in their judgment under the circumstances. I/we hereby authorize and direct the above named to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act, of a dentist licensed under the provisions of the Dental Practice Act, and on the staff of any general hospital holding a current license to operate a hospital from the State Department of Public Health or its equivalent. This authorization is effective whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere. I/we hereby accept responsibility for any expenses related to any treatment and/or treatment-related transportation or other cost, and that under no circumstance shall any such costs be charged to, or claimed from, KCB or MMTSC. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of my aforementioned agents to give specific consent to any and all such diagnosis which in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned before rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I also agree that this authorization to treat shall be valid in any state where such treatment is rendered. I also agree that if English is not my first language that I have sought out someone to translate this form to me and agree that by my signature that I have read and understood the document. A photocopy of this Authorization will have the effect as the original.

Authorization and Consent for Medical Treatment. I/we the undersigned parent, parents or legal guardian of the above named minor, do hereby authorize in the event of an injury, accident, or illness, ARARATthe Tournament Host, its coaches, team representatives, directors, officers, agents, and assignees to seek and obtain care and medical treatment as shall be necessary under the circumstances. I/we hereby authorize and direct the above named to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act, of a dentist licensed under the provisions of the Dental Practice Act, and on the staff of any general hospital holding a current license to operate a hospital from the State Department of Public Health or its equivalent. This authorization is effective whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of my aforementioned agents to give specific consent to any and all such diagnosis which in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned before rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I also agree that this authorization to treat shall be valid in any state where such treatment is rendered. I also agree that if English is not my first language that I have sought out someone to translate this form to me and agree that by my signature that I have read and understood the document. (Parent/Guardian Release) I am the parent or legal guardian of the minor listed on Page 3, and I am signing this waiver on Page 3, indemnification and release of liability agreement on behalf of said minor. The coaches are fully responsible for obtaining the signature of the parents. A photocopy of this Authorization Waiver and Release of Liability Agreement will have the same effect as the original. This consent shall remain effective until December 31, 2017. Swift Tournament Name: ________________________ Date: _____________ Team Name: Athlete’s Printed Name Parent’s Signature Emergency/Cell Phone 1 _____________________________________ ______________________________________ _________________________ 2 _____________________________________ ______________________________________ _________________________ 3 _____________________________________ ______________________________________ _________________________ 4 _____________________________________ ______________________________________ _________________________ 5 _____________________________________ ______________________________________ _________________________ 6 _____________________________________ ______________________________________ _________________________ 7 _____________________________________ ______________________________________ _________________________ 8 _____________________________________ ______________________________________ _________________________ 9 _____________________________________ ______________________________________ _________________________ 10 _____________________________________ ______________________________________ _________________________ 11 _____________________________________ ______________________________________ _________________________ 12 _____________________________________ ______________________________________ _________________________ 13 _____________________________________ ______________________________________ _________________________ 14 _____________________________________ ______________________________________ _________________________ 15 _____________________________________ ______________________________________ _________________________ Coach _____________________________________ ______________________________________ _________________________ Coach _____________________________________ ______________________________________ _________________________ Coaches are responsible for obtaining signatures of the parents/guardians. Coaches must have ALL addresses and emergency contact information in his/her possession. This completed form must be turned in prior to the start of your first game.

Authorization and Consent for Medical Treatment. I/we WE the undersigned parent, parents or legal guardian of the above named minor, do hereby authorize in the event of an injury, accident, or illness, ARARATTNBA, its coaches, team representatives, directors, officers, agents, and assignees to seek and obtain care and medical treatment as shall be necessary under the circumstances. I/we hereby authorize and direct the above named to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act, of a dentist licensed under the provisions of the Dental Practice Act, and on the staff of any general hospital holding a current license to operate a hospital from the State Department of Public Health or its equivalent. This authorization is effective whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of my aforementioned agents to give specific consent to any and all such diagnosis which in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned before rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I also agree that this authorization to treat shall be valid in any state where such treatment is rendered. I also agree that if English is not my first language that I have sought out someone to translate this form to me and agree that by my signature that I have read and understood the document. A photocopy of this Authorization will have the effect as the original. Signatures on Page 4.

Authorization and Consent for Medical Treatment. I/we the undersigned parent, parents or legal guardian of the above named minor, do hereby authorize in the event of an injury, accident, or illness, ARARATthe Tournament Host, its coaches, team representatives, directors, officers, agents, and assignees to seek and obtain care and medical treatment as shall be necessary under the circumstances. I/we hereby authorize and direct the above named to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act, of a dentist licensed under the provisions of the Dental Practice Act, and on the staff of any general hospital holding a current license to operate a hospital from the State Department of Public Health or its equivalent. This authorization is effective whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of my aforementioned agents to give specific consent to any and all such diagnosis which in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned before rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I also agree that this authorization to treat shall be valid in any state where such treatment is rendered. I also agree that if English is not my first language that I have sought out someone to translate this form to me and agree that by my signature that I have read and understood the document. (Parent/Guardian Release) I am the parent or legal guardian of the minor listed on Page 3, and I am signing this waiver on Page 3, indemnification and release of liability agreement on behalf of said minor. The coaches are fully responsible for obtaining the signature of the parents. A photocopy of this Authorization Waiver and Release of Liability Agreement will have the same effect as the original. This consent shall remain effective until December 31, 2020. Swift Tournament Name: ________________________ Date: _____________ Team Name: Athlete’s Printed Name Parent’s Signature Emergency/Cell Phone 1 _____________________________________ ______________________________________ _________________________ 2 _____________________________________ ______________________________________ _________________________ 3 _____________________________________ ______________________________________ _________________________ 4 _____________________________________ ______________________________________ _________________________ 5 _____________________________________ ______________________________________ _________________________ 6 _____________________________________ ______________________________________ _________________________ 7 _____________________________________ ______________________________________ _________________________ 8 _____________________________________ ______________________________________ _________________________ 9 _____________________________________ ______________________________________ _________________________ 10 _____________________________________ ______________________________________ _________________________ 11 _____________________________________ ______________________________________ _________________________ 12 _____________________________________ ______________________________________ _________________________ 13 _____________________________________ ______________________________________ _________________________ 14 _____________________________________ ______________________________________ _________________________ 15 _____________________________________ ______________________________________ _________________________ Coach _____________________________________ ______________________________________ _________________________ Coach _____________________________________ ______________________________________ _________________________ Coaches are responsible for obtaining signatures of the parents/guardians. Coaches must have ALL addresses and emergency contact information in his/her possession. This completed form must be turned in prior to the start of your first game.

Authorization and Consent for Medical Treatment. I/we the undersigned parent, parents or legal guardian of the above named minor, do hereby authorize in the event of an injury, accident, or illness, ARARAT, its coaches, team representatives, directors, officers, agents, and assignees to seek and obtain care and medical treatment as shall be necessary under the circumstances. I/we hereby authorize and direct the above named to consent to any x-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is deemed advisable and rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act, of a dentist licensed under the provisions of the Dental Practice Act, and on the staff of any general hospital holding a current license to operate a hospital from the State Department of Public Health or its equivalent. This authorization is effective whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of my aforementioned agents to give specific consent to any and all such diagnosis which in the exercise of his or her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned before rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. I also agree that this authorization to treat shall be valid in any state where such treatment is rendered. I also agree that if English is not my first language that I have sought out someone to translate this form to me and agree that by my signature that I have read and understood the document. A photocopy of this Authorization will have the effect as the original.. PERMISSION – USE OF NAME AND LIKENESS FOR PUBLICITY AND