Fillable Authorization To Consent To Treatment Of A Minor printable pdf download

Medical /Liability Release Form

AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR

(I), (We), the undersigned, the parent(s)/guardian(s) of ________________________, a minor, do hereby authorize Science Explorers, Inc. and

contractors, for the undersigned to consent to any emergency treatment deemed advisable by, and rendered under the general or specific

supervision of any physician/surgeon licensed under the provisions of the Medical Practices Act on the medical staff of a licensed hospital, whether

such diagnosis or treatment is rendered at the office of said physician or said hospital. It is understood that this authorization is given in advance of

any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to

give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician, in the exercise of his/her best

judgment, may deem advisable.

We have registered our child for this program and have given permission for said child to attend and participate in the Science Explorers Camp.

Date: _____________________

Name of Child: _________________________________________________________________

Health Insurance Provider: __________________________________ Health Insurance Policy Number: ______________________

My child has the following conditions or allergies that may occur: _______________________________________________________

Parent(s) or Legal Guardian(s): ______________________________________________________________________ Please print

Parent(s) or Legal Guardian(s): _______________________________________________________________________Signature(s)

LIABILITY RELEASE

I, the undersigned, agree to save and hold harmless Science Explorers, Inc. and respective departments, organizations, boards, commissions,

officers, agents, and employees and contractors from any liability whatsoever for any harm, personal injury, or property damage which I or my child

______________________________________________ may cause or suffer arising out of his/her participation in the Science Explorers Program.

Parent(s) or Legal Guardian(s): _______________________________________________________________________ Please Print

Parent(s) or Legal Guardian(s): _______________________________________________________________________ Signature(s)

ADMINISTERING MEDICATION

If your child needs medication to be administered during the camp day, please review and sign the following:

Check one:

My child does not need medication during the camp day.

My child does need medication during the camp day.

The medication, in its original container must be labeled with a prescription by a pharmacist or a physician. DO NOT send unlabeled containers to

camp. Any medication that comes under the law of controlled substances (such as Ritalin) must be presented to the camp instructor by the

parent/guardian. All medications will be kept in the instructor’s possession. Campers who need to self-administer medications (such as inhalers) are

permitted to do so with the instructor’s permission and are required to report each self-administered dose to the instructor.

I hereby grant permission for the instructor to oversee the intake of medication to my child as listed below:

Parent(s) or Legal Guardian(s): _______________________________________________________________________ Please Print

Parent(s) or Legal Guardian(s): _______________________________________________________________________ Signature(s)

Name of Child __________________________ Grade __________

Name of Medication _______________________________

Time to be given ____________ Amount to be given ___________ Possible Side Effects _________________________________

Additional Instructions _________________________________________________________________________________________

Camp Location______________________________________________________________________ Date ____________________

Authorization To Consent To Treatment Of A Minor

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