Permission to Treat. I understand that by signing below I authorize TCFAP to provide medical care reasonable by today’s standards. Initial for Permission to Treat *I understand that by signing this agreement, I agree to all of the terms and conditions described above, even if I have not not signed my intials at the end of each section.*
Permission to Treat. St. Mark’s School’s policy is to give parents prompt notice of a student’s illness or injury, and to obtain approval of procedures to be followed thereafter. However, emergency situations may arise where delay involved in attempting to contact parents may jeopardize a student’s recovery. I hereby consent for St. Mark’s School personnel to obtain medical care for my daughter/son in the event of illness or injury as they judge to be in my son/daughter’s best interests, and to exchange pertinent personal medical history and/or health insurance information as necessary for the provision of medical services. Parent/Guardian signature: Date:
Permission to Treat. I hereby authorize and give my consent to any licensed health professional to perform upon or administer to (student’s name) any reasonable, necessary treatment. In the case of a psychiatric and/or psychological emergencies involving psychological treatment, parental notification for treatment beyond that responsive to the emergency will be requested. This authorization is intended to include emergency treatment, immunizations, injections, and minor operations and procedures. I also give permission to administer whatever anesthetic may be necessary or advisable during medical or surgical procedures. I agree to assume all costs related to such treatment. I authorize my insurance company to pay benefits to any licensed health service provider. Also, I authorize the disclosure of medical information to my insurance company for the purpose of this claim. This permission is only valid while the student is attending the Cogito World Education/Colibri Group LLC summer 2017 SAT camp.
Permission to Treat. I understand that by signing below I authorize SP to provide medical care reasonable by today’s standards.
Permission to Treat. I understand every effort will be made to contact me in the case of an emergency. If needed, Trinity staff will obtain immediate medical attention for my child. Efforts will be made to obtain treatment from the providers listed on my child’s emergency card. Yes No Photograph Release Permission I give permission for any picture or video taken of my child to be used in any type of educational publication, in newspapers, on bulletin boards, or part of the classroom to be videotaped for Trinity training or marketing purposes. Yes No Topical Applications The Trinity staff has permission to administer the following applications, if needed, for my child during the Trinity Trailblazer program. My child has not had an allergic reaction, which I am aware of, to the products that I am supplying and giving permission to apply. Yes No Vaseline/Petroleum jelly /Lip balm Please list brand name Insect Repellent Please list brand name Sun-Block (SPF 30 or higher) Please list brand name Parent/Guardian Signature Date
Permission to Treat. I hereby give permission to trained medical professionals to administer emergency medical treatment to my child should sickness or illness occur in my absence: Yes Student Information: First Name No Last Name Date of Birth Age Class Name 1. 2. 3.
Permission to Treat. I, , as the patient or parent/guardian of the patient do hereby give Premier Glaucoma & Eye Center permission to treat for any vision or other problems related to his/her eyes using whatever ophthalmic testing and treatments deemed medically necessary. This permission is valid for one year form the date on this form.
Permission to Treat. I understand every effort will be made to contact me in the case of an emergency. If needed, Trinity staff will obtain immediate medical attention for my child. Efforts will be made to obtain treatment from the providers listed on my child’s emergency card. Yes No Photograph Release Permission I give permission for any picture or video taken of my child to be used in any type of educational publication, in newspapers, on bulletin boards, or part of the classroom to be videotaped for Trinity training or marketing purposes. Yes No Parent/Guardian Signature Date
