Health History, Emergency Contact Information Permission To Treat With First Aid And Medical Authorization
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1
2Health History, Emergency Contact Information
Permission to Treat with First Aid and Medical Authorization
295 Busch Blvd
Columbus, OH 43229
614 888-8393
6
Child Name:
_________________________________________________________________________________________________________________________________________________________
Address:
_________________________________________________________________________________________________________________________________________________________
Mother/Guardian’s Name: __________________________________________________________________________________________________________________
Day Phone (
) __________________________________________ Evening Phone (
) ______________________________________________________________________
Father/Guardian’s Name: ___________________________________________________________________________________________________________________
Day Phone (
) __________________________________________ Evening Phone (
) ____________________________________________________________________
Emergency Contact: ___________________________________________________________________________________________________________________________
(
) _______________________________________________________
Day Phone (
) _________________________________________________ Evening Phone
PLEASE FILL OUT EITHER SECTION ONE (CONSENT FOR MEDICAL TREATMENT) OR SECTION TW O
(REFUSAL OF CONSENT FOR TREATMENT). THE REVERSE SIDE OF THIS FORM CONATINS MEDICAL
HISTORY INFORMATION WHICH SHOULD BE COMPLETED AND ACKNOWLEDGED BY THE PARENT
OR GUARDIAN OF THE MINOR CHILD.
Section 1
Authorization to permit medical treatm ent . By signing below, I hereby give permission to the Vertical
Adventures, their employees, members, or volunteers to provide routine first aid and to supervise self-
medication and to seek medical assistance on behalf of my child in the event my child is injured or becomes ill,
and I am unavailable to indicate my wishes regarding treatment. I understand that the Vertical Adventures and
its members, volunteers, or employees shall not be held responsible for the cost of treatment, and in fact are
authorized to bind me as the financially responsible party for the medical treatment of my child. I hereby grant
permission to physicians and other licensed health care providers and their designees to administer medical
care through injury or illness evaluation, first aid care, and referral to duly licensed medical personnel when
indicated
.
Date Granted
Signature of Parent Guardian
Section 2
Refusal to consent to m edical treatment. By signing below, I indicate that Vertical Adventures
Its volunteers, or employees are not authorized to allow the administration of health care to my child in the
event of injury or sickness. However, I will not hold the Vertical Adventures, its employees, members, or
volunteers liable in any way for seeking emergency care (such as calling 911) for my child or providing any health
information on this form to emergency personnel.
Date Granted
Signature of Parent Guardian
MEDICAL HISTORY INFORM ATION M UST BE COM PLETED ON THE REVERSE SIDE OF THIS FORM .
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