AUTHORIZATION FOR MEDICAL TREATMENT. In the event that I cannot be reached to make arrangements for medical treatment, I authorize YMCA Staff to administer first aid/or transport to the nearest hospital or emergency care facility. Name of Licensed Physician or Emergency-Care Facility: _________________________________________________________________________ Street Address: _____________________________________________________ City: _______________________ State: _______ Zip: ____________________ Phone Number:______________________________________________________ I certify that has been examined by a licensed physician in the past 12 months, is able to participate in the YMCA Day Camp Program. The Health History is correct as far as I know, and the person herein described has permission to engage in all prescribed activities and fieldtrips, except as noted by the examining physician and me. Parent Signature: _____________________________ Date: ___________ ADMISSION AGREEMENT
AUTHORIZATION FOR MEDICAL TREATMENT. I authorize Right Dose, at the direction of my physician, to provide medications to me. I certify that no guarantee or promise, express or implied, has been made to me in conjunction with the medications that have been prescribed for me.
AUTHORIZATION FOR MEDICAL TREATMENT. “If an accident happens and if I cannot be reasonably reached, I give permission for emergency medical treatment and promise to cover medical costs if treatment is needed.” I understand it may be necessary to have a medical consent form present for medical professionals in the unlikely event of an injury or condition requiring medical treatment of me or my child. This form gives YFC and its personnel the permission to take me or my child to the nearest, capable medical facility and have any necessary emergency treatment administered.
AUTHORIZATION FOR MEDICAL TREATMENT. In the event of an emergency, I do hereby authorize any and all medical treatment to be provided to me including, without limitation, emergency treatment and transportation, X-ray, anesthetic, dental, medical or surgical diagnosis or treatment by any licensed physician or dentist, as applicable, and any hospital services that might be rendered on my behalf. I hereby assume all responsibility for the expenses associated with the performance of such services. This permission may be revoked at any time by providing notification in writing to the Admission’s Office.
AUTHORIZATION FOR MEDICAL TREATMENT. I authorize my physician(s) and his/her designee(s), other individuals with privileges to provide services at BCDI, and their employees to provide medical services to me, including diagnostic tests and therapeutic procedures necessary for the diagnosis and treatment of my illness or condition. Treatment means the provision, coordination or management of your health care, including consultations between health care providers relating to your care and referrals for health care from one health care provider to another. I further authorize medical care, testing, and treatment as necessary in emergency situations to preserve my life and the health of persons involved in my care without first obtaining consent from me or my family. I understand that BCDI may be a teaching institution, providing clinical training opportunities for medical, nursing, and allied health student and residents. I consent to such students and residents being involved in my care and treatment and understand that they are not employees of my physician or BCDI.
AUTHORIZATION FOR MEDICAL TREATMENT. I authorize Guardian Pharmacy of Michigan, at the direction of my physician, to provide medications to me. I certify that no guarantee or promise, express or implied, has been made to me in conjunction with the medications that have been prescribed for me.
AUTHORIZATION FOR MEDICAL TREATMENT. I hereby authorize medical treatment for the minor child for whom I am guardian or otherwise responsible (who is listed below), at my cost, if the need arises, however I acknowledge that the Released Parties shall have no duty, obligation or liability arising out of the provision of, or failure to provide or administer medical care or treatment.
AUTHORIZATION FOR MEDICAL TREATMENT. In recognition of the risks, which I am assuming by voluntarily participating in these activities, I hereby give TAKE FLIGHT, its agents and employees permission to treat me and to authorize medical treatment of me in the case of an emergency or accident. Participant Address: City: State: Zip Code: Phone: E-Mail Address: CAUTION! DO NOT SIGN THIS RELEASE IF YOU DO NOT AGREE WITH OR DO NOT UNDERSTAND ITS TERMS I understand that my involvement and participation in these activities is voluntary. I have the right and will notify TAKE FLIGHT if I do not want to participate in any or all of the activities. I will not allow my family or other participants in my group to influence my decision whether to participate. If at any time I am unsure, frightened, or unable to proceed I will immediately notify TAKE FLIGHT employees, who will assist me in continuing or in exiting the course. I HAVE READ THIS PARTICIPANT AGREEMENT, RELEASE AND ACKNOWLEDGEMENT OF RISK. I FULLY UNDERSTAND ITS TERMS, AND THAT I HAVE GIVEN UP LEGAL RIGHTS, AND I SIGN IT FREELY AND VOLUNTARILY. Signature of Adult Participant Printed Name of Adult Participant Date FOR PARTICIPANTS OF MINORITY AGE (under 18 years of age): As parent, guardian, or temporary guardian with legal responsibility for the below-named Minor(s), this is to certify that I have read the entirety of this document, and that by signing below on behalf of said Minor(s), the Minor(s) and I are bound by its terms. I hereby consent and agree to participation by said Minor(s) in the activities, and on behalf of myself and said Minor(s), I and said Minor(s) hereby agree to release, indemnify, defend and hold harmless the Released Parties from any and all loss, cost, claim, damage, injury or death to person or property arising from participation of said Minor(s) in the activities. IN THE EVENT THAT I AM NOT THE PARENT OR LEGAL GUARDIAN OF THE MINOR(S), OR I DID NOT HAVE THE LEGAL CAPACITY OR AUTHORITY TO EXECUTE THIS AGREEMENT ON BEHALF OF THE MINOR(S), THEN I AGREE TO DEFEND, HOLD HARMLESS AND INDEMNIFY THE RELEASED PARTIES FROM AND AGAINST ANY CLAIMS OR SUITS INSTITUTED AGAINST THE RELATED PARTIES AS A RESULT OF ANY LOSS, COST, CLAIM, LIABILITY, INJURY OR DEATH TO PERSON OR PROPERTY ARISING OUT OF, RELATING TO, OR IN ANY WAY CONNECTED WITH PARTICIPATION BY SAID MINOR(S) IN THE ACTIVITIES. Signature of Parent/Adult Legal Guardian Printed Name of Parent or Adult Legal Guardian if Participant is a Minor Date
AUTHORIZATION FOR MEDICAL TREATMENT. I authorize Publix Specialty Pharmacy, under the direction of my physician, to provide my medications to me. I have been instructed by my physician about my prescribed medications and understand the reasons why they are considered necessary, their risks, advantages, possible complications, and alternatives. As in any medication therapy, I understand that there are known and unknown risks. I certify that no guarantee or promise, expressed or implied, has been made to me in conjunction with the medications that have been prescribed for me.
AUTHORIZATION FOR MEDICAL TREATMENT. I authorize [MTPS], at the direction of my physician, to provide medications to me. I certify that no guarantee or promise, express or implied, has been made to me in conjunction with the medications that have been prescribed for me.
