Common use of Consent for Emergency Treatment Clause in Contracts

Consent for Emergency Treatment. I authorize the University of Wisconsin-Xxxxxxx Point and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s):

Consent for Emergency Treatment. I authorize the University of Wisconsin-Xxxxxxx Point and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s)::

Consent for Emergency Treatment. I authorize the University of Wisconsin-Xxxxxxx Point and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s)::

Consent for Emergency Treatment. I authorize the University of Wisconsin-Xxxxxxx Point and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s):): *For Office Use Only Belay School Completed: Instructor’s Signature Date:

Consent for Emergency Treatment. I authorize the University of Wisconsin-Xxxxxxx Point Fond du Lac and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian (if If Participant is Under under 18*): Date: Emergency Contact Information: Name: Address: Phone(s):*If your son, daughter or xxxx will be under 18 while participating in at the University of Wisconsin –

Consent for Emergency Treatment. I authorize the University of Wisconsin-Xxxxxxx Point and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s):Guardian

Consent for Emergency Treatment. I authorize the University of Wisconsin-Wisconsin – Xxxxxxx Point and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact InformationDate: ------------------------------------------------------------------Administrative Use Below-------------------------------------------------------------------------------- Step 1. Print Name & Date: Staff Name: Address: Phone(s):Date:

Consent for Emergency Treatment. I authorize the University of Wisconsin-Xxxxxxx Point Wisconsin­Oshkosh and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Initial: I understand and agree to the above statements: Signature: Date: Signature of Parent or Guardian (if If Participant is Under under 18*): Date: Emergency Contact Information: Name: Address: Phone(s)::

Consent for Emergency Treatment. I authorize the University of Wisconsin-Wisconsin Xxxxxxx Point at Wausau and its designated representatives to consent, on my behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. Signature: Date: Signature of Parent or Guardian (if Participant is Under 18): Date: Emergency Contact Information: Name: Address: Phone(s):Guardian