PERMISSION FOR EMERGENCY MEDICAL CARE. In the event of an emergency affecting the life or permanent well-being of My Child, I authorize any licensed physician, emergency medical technician, paramedic, nurse, hospital or other medical facility to treat My Child, including the authority to admit My Child to the hospital and provide medical and hospital care and treatment for My Child, including having surgery, anesthesia, blood and blood products, if necessary. I understand that by executing this form I am not relieved of any financial or other obligations regarding My Child for which I am legally responsible. On behalf of myself and My Child, I release and agree to the fullest extent permitted by law, to save, hold harmless and indemnify Member and its officials, employees, volunteers and agents from any and all liability for loss, cost, claim or damage whatsoever that may be imposed on or incurred by them because of the participation or attendance of My Child. No
PERMISSION FOR EMERGENCY MEDICAL CARE. In the event of a medical emergency involving the me (+/or child) listed above and after reasonable attempts to contact me at (phone#s), or (other parent/guardian) at (phone#s) have not been successful, I hereby give permission for the pastors and/or volunteer lay leaders of the Xxxxx River Baptist Church, or sponsoring church/organization to (1) arrange for the administration of any medical treatment deemed necessary by Dr. (preferred physician) at (phone#), or Dr. (preferred dentist) at (phone#), or in the event the designated practitioner(s) is/are not available, by another licensed physician or dentist; and (2) the transfer of myself +/or child to the offices of the designated practitioner(s) above, to another licensed physician or dentist or to , (preferred hospital) or to any other hospital that, in view of the nature of the emergency, is in the opinion of licensed medical and/or emergency personnel deemed to be reasonably accessible. This authorization does not cover major surgery unless the medical opinion of two licensed physicians or dentists concurring in the necessity for such surgery are obtained prior to the performance of such surgery. Facts concerning my / the child’s medical history, including allergies, medications being taken, any medical conditions +/or physical impairments to which a physician should be alerted are as follows: , 202 Signature of Parent/Guardian/Adult Participant Date PARENTS/GUARDIANS ARE RESPONSIBLE FOR CONTACTING XXXXX RIVER BAPTIST CHURCH DIRECTLY or THE OFFICE WHEN AND IF THE DATA GIVEN ABOVE CHANGES FOR ANY REASON.
PERMISSION FOR EMERGENCY MEDICAL CARE. In order to meet all legal requirements, I hereby authorize representatives of the Meadowlands Area YMCA to give consent for any and all emergency medical care for my child while said child attends programs sponsored by the Meadowlands Area YMCA. / / ______ Parent/Guardian Signature (M) (D) (Y) APPROVED INDIVIDUALS FOR PICK UP & EMERGENCY CONTACTS/PICK UP PLAN LIST ALL PERSONS APPROVED TO PICK UP THE CHILD, INCLUDING PARENT/GUARDIANS. THE CHILD WILL NOT BE RELEASED TO ANYONE ELSE WITHOUT WRITTEN PERMISSION FROM PARENTS/GUARDIANS. PLEASE NOTE THAT THESE INDIVIDUALS MUST BE ABLE TO PROVIDE PHOTO IDENTIFICATION TO YMCA STAFF. You are required to have an Emergency Pick Up Plan for your child. In the event that the school building is closed unexpectedly, due to inclement weather, loss of electricity, etc., the School Age Child Care program may be cancelled. If such a situation should arise, we need to know whom to call if we are unable to contact you. Please make advanced arrangements with three adults upon whom we may call to quickly pick up your child. Please list them below with all the required information. We recommend that you choose adults who reside or work close to the school. Any additional individuals can be added on another sheet of paper if necessary. It is sometimes necessary to contact a parent or guardian during the day because of accident, illness or absenteeism. We will try to contact parents/guardians first. However, if we are unable to contact you, we will call the people listed below. NAME RELATIONSHIP
