Consent for Emergency Treatment. I authorize the University of Wisconsin - Superior 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
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 – Green Bay 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.
Consent for Emergency Treatment. The undersigned, as a participant in the subject activity, hereby consent to medical treatment in a medical emergency where the undersigned is unable to consent to such treatment.
Consent for Emergency Treatment. I authorize the Releasees, and their 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
Consent for Emergency Treatment. I authorize the University of Wisconsin-Whitewater 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: *If your son, daughter or xxxx will be under 18 while participating, it is our policy to request your agreement to the above terms on behalf of your minor son, daughter or xxxx.
Consent for Emergency Treatment. I authorize the University of Wisconsin – Extension - Ozaukee County 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
Consent for Emergency Treatment. I authorize the University of Wisconsin-Madison, the Xxxxx Xxxxxxxx American Family Insurance Foundation, and the American Family Mutual Insurance Company, S.I and their 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:
Consent for Emergency Treatment. In the event of a serious injury, the registrant authorizes the University of Wisconsin-Whitewater and its designated representatives to consent, on their behalf, to any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. Registrants agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
Consent for Emergency Treatment. I authorize UW-OSHKOSH 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
