Consent to Emergency Medical Treatment. The health history above is correct as far as I know, and the Participant has permission to engage in all Program activities noted by me and the examining medical practitioner. I grant Yale, its officers, trustees, agents, employees, students, or volunteers (“Released Parties”) permission to authorize emergency medical and surgical treatment for the Participant, as they deem appropriate. I understand and agree that the Released Parties assume no responsibility for any injury or damage that might arise out of, or in connection, with such authorized emergency medical treatment. Printed Name of Parent/Legal Guardian:
Consent to Emergency Medical Treatment. The health history above is correct as far as I know, and the Participant has permission to engage in all Program activities noted by me and the examining medical practitioner. I grant Yale, its officers, trustees, agents, employees, students, or volunteers (“Released Parties”) permission to authorize emergency medical and surgical treatment for the Participant, as they deem appropriate. I understand and agree that the Released Parties assume no responsibility for any injury or damage that might arise out of, or in connection, with such authorized emergency medical treatment. Printed Name:
Consent to Emergency Medical Treatment. In the event the above named player required emergency medical treatment and neither parent nor guardian is present to consent, I do hereby consent to such emergency medical treatment as may be required. Acknowledgement of Consent: Parent Signature: Date:
Consent to Emergency Medical Treatment. I give consent and permission to the “Park”, NESC, or any other Covered Party to obtain on behalf of myself or my minor child any emergency medical attention and treatment in case of sickness, accident or injury and to secure such medical attention and treatment at my sole expense. I recognize that it may be required to transport my minor child to the nearest medical treatment facility based upon their age even though their condition may not warrant it. By signing this document, the undersigned fully recognize that if the Participant or another participant is hurt or property is damaged while the Participant is engaged in this activity, then the undersigned will have no right to make a claim or to file a lawsuit against the Covered Parties, even if they or any of them negligently caused the bodily injury or property damage. The undersigned further agrees that this Agreement is intended to be as broad and inclusive as is permitted by the law of the State of New Hampshire and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Initials of Participant Initials of Parent/Guardian Page 4 of 5 I HEREBY CERTIFY THAT I AM OVER 18 YEARS OF AGE OR I AM HAVING MY LEGAL GUARDIAN SIGN THIS DOCUMENT ALSO. I HAVE CAREFULLY READ THE FOREGOING AND ACKNOWLEDGE THAT I UNDERSTAND AND AGREE TO ALL OF THE ABOVE TERMS AND CONDITIONS AND SIGN IT VOLUNTARILY. PRIOR TO SIGNING THIS AGREEMENT, I HAVE REVIEWED THE PARK SAFETY RULES AND REGULATIONS, AND HAVE HAD THE OPPORTUNITY TO ASK ANY AND ALL QUESTIONS ABOUT THE “PARK”, THE PARK STAFF AND/OR THIS AGREEMENT. I AM AWARE THAT BY SIGNING THIS AGREEMENT, I, ON MY OWN BEHALF AND ON BEHALF OF THE PARTICIPANT, ASSUME ALL RISKS AND WAIVE AND RELEASE CERTAIN SUBSTANTIAL RIGHTS THAT I, MY HEIRS, NEXT OF KIN, FAMILY, RELATIVES, GUARDIANS, EXECUTORS, ADMINISTRATORS TRUSTEES AND ASSIGNS OR THE PARTICIPANT MAY HAVE OR POSSESS AGAINST THE “PARK”, NESC, OR ANY OTHER COVERED PARTY. Participant’s Name: Participant’s Birthday: Participant’s or Parent’s Drivers License Number: State: Address: City: State: Zip: Home Phone Number: ( ) - Parent Name or Emergency Contact: Emergency Phone Numbers: ( ) - Cell Pager Office Home Other ( ) - Cell Pager Office Home Other Please Note Any Information that Rye Airfield should be aware of (use back if necessary): Participant’s signature: Today’s Date: HOW DID YOU HEAR ABOUT RYE AIRFIELD? (If the Participant is below age 18:) IN ...
Consent to Emergency Medical Treatment. I consent to all emergency medical treatment that is deemed necessary by first responders and health care providers, until such time that I—or a guardian or person legally authorized to decide for me—is able to make medical decisions. I agree that I am responsible for all costs of treatment.
Consent to Emergency Medical Treatment. I, the parent/legal guardian of the mentioned named minor Child, give full authority to the Blind Children's Learning Center (BCLC) and its officers, employees, and agents to take whatever action they deem is warranted, under the circumstances of the emergency, and to act as agent of the Child and myself, the parent/legal guardian, at my expense, regarding the Child's health and safety. This full authority includes giving permission to a physician, paramedic, and/or health care facility to render medical treatment to the Child, including the giving of medication, medical examinations, X-rays, anesthetic, medical and/or surgical diagnosis and hospital care, when deemed necessary by the attending medical professional. I fully acknowledge, as the Child's parent/legal guardian, that this CONSENT is not given in advance of any specific diagnosis, treatment or health care facility being required. BCLC has a series of Policies in place for the safety and health of your Child. You may obtain a copy of any or all of those Policies, upon request. BCLC Policy No. B-XII provides for the Child's legal representative to prohibit the use of a medical physician's involvement in the medical treatment of the Child, because of a religious faith/other spiritual means. If BCLC has not received a written statement of refusal to obtain a physician's medical assessment, a written statement that no medical care be given to the Child, and a written statement accepting full responsibility for the Child's health, BCLC will put into effect the full authority of providing EMERGENCY MEDICAL TREATMENT, as stated in the first paragraph of this document. The BCLC HOLD HARMLESS AGREEMENT is applicable to this Document. I have read and understand fully, all elements of this CONSENT TO EMERGENCY MEDICAL TREATMENT document. I further understand fully that this DOCUMENT is legally binding in all terms presented herein. As Parent/Legal Guardian of mentioned named Child, I represent to you that I am legally authorized to sign this CONSENT TO EMERGENCY MEDICAL TREATMENT.
Consent to Emergency Medical Treatment. I give consent and permission to TS2 COACHING to obtain on my behalf any emergency medical treatment in the case of sickness, accident, or injury and to secure such medical attention at my expense. Nothing in this Agreement shall create an obligation or duty for TS2 COACHING to obtain emergency or any other medical treatment for me nor make TS2 COACHING responsible for any treatment obtained or provided hereunder.
Consent to Emergency Medical Treatment. The telephone number to contact in case of medical emergency appears below. If Rocket Man Pole Vault, LLC; Xxxxxxxxxx Properties, LLC; Velocity Track Systems, LLC are unable to make contact at that number to obtain consent to treatment, Participant, Coach , and Parent each authorize, but do not obligate, Rocket Man Pole Vault, LLC; Xxxxxxxxxx Properties, LLC; Velocity Track Systems, LLC to their respective authorized agents to consent to emergency medical treatment of Participant. Neither Rocket Man Pole Vault, LLC; Xxxxxxxxxx Properties, LLC; Velocity Track Systems, LLC shall be under any obligation to pay the cost of such treatment.
Consent to Emergency Medical Treatment. While participating in the program(s), I acknowledge that, on rare occasions, an emer- gency may develop which necessitates the administration of medical care, hospitaliza- tion or surgery. I have fully described any physical or psychological problems I may have on the Student Information Form. In the event of illness or injury to me that would prevent me from authorizing my own treatment, I authorize any official representative of BWRC to secure medical treatment on my behalf, including surgery and the administration of anaesthesia, and I accept all financial responsibility for such treatment.
Consent to Emergency Medical Treatment. I understand that on rare occasions an emergency may develop which necessitates the administration of medical care, hospitalization or surgery. Therefore, in the event of injury or illness to myself necessitating emergency medical care, I hereby authorize North American Disease Intervention, by and through its authorized representative(s) or agent(s), to secure any necessary treatment. It is understood that such treatment shall be solely at my expense.
