Release Authorization (Page 10 of 13) in pdf

PENSACOLA CHRISTIAN COLLEGE

PENSACOLA CHRISTIAN

COLLEGE

PENSACOLA CHRISTIAN

COLLEGE

Pensacola, Florida

POWER OF ATTORNEY FORM

Shaded areas must be filled out by the parent or guardian.

Student Name

Gender

Birthdate

Age

Last

First

Middle

M/F

Month/Day/Year

This is to certify that I/we,

and

parent(s)/guardian(s) of the minor listed above do hereby consent to and appoint the Vice President for Student Life, the

assistants to said person, or affiliate employees of Pensacola Christian College, Inc. (“Appointees”), P.O. Box 18000,

Pensacola, Florida 32523-9160, U.S.A., as our true and lawful attorneys with the power to authorize and consent to the

administration of any anesthetic or medical treatment and performance of whatever operation, procedure, or removal of tissue

decided to be necessary by the attending physician or medical provider on the above-named minor for the period of his/her

registration at Pensacola Christian College.

Neither the Appointees nor Pensacola Christian College, Inc. (including its affiliates and subsidiaries) shall incur any liability

whatsoever by reason of the giving of any authority or consent to treatment hereunder, and there is no obligation on

Pensacola Christian College, Inc., or the Appointees to be available to exercise this power of attorney should the minor need

medical attention.

In consideration of the above-named Appointees’ exercise of this contract, authorized hereunder, the undersigned agree to

hold harmless and indemnify said Appointees and Pensacola Christian College, Inc., its affiliates and subsidiaries, along with

its and their officers, directors, employees, agents, contractors, and/or successors and assigns, from and against any liability

whatsoever arising from the administration of any anesthetic or any medical treatment or procedure or performance of any

operation or the removal of any tissue as a result of any consent hereunder without any limitation of the foregoing. This

indemnifying agreement shall apply to any liability whatsoever, whether presently known or unknown, or anticipated or

unanticipated, arising by reason of the giving of any consent hereunder.

MUST BE COMPLETED IN FULL

County

State

Signature of Parent(s) or Guardian(s):

Before the undersigned Notary Public, personally appeared

Signature

Relationship

who

Parent/Guardian Name

Signature

Relationship

is personally known to me / has produced identification

Address

City

State

(state type of ID)

and who did / did not take an oath.

Country

Telephone numbers in case of emergency:

Given under my hand and official seal this

day of

Special Medical Information Regarding Student:

1. Has a heart condition

Notary Public

2. Is diabetic

My commission expires

3. Has epilepsy

4. Is allergic to

Notary Seal

5. Had tetanus shot on

Had most recent booster on

6. Take to military hospital ONLY

7. Other medical information

10/12 AMS

Release Authorization Page 10

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