Minor Volunteer Release And Authorization To Treat Form (Page 2 of 2) in pdf

Minor Volunteer Release And Authorization To Treat Form Page 2

[5] Authorization for Medical Treatment

If my minor child is injured in an accident or suffering from an illness, disease, or condition that, if not

treated or cared for without delay, would endanger the physical health or well-being of my minor child, I

grant HOJ permission to seek emergency medical care for my minor child.

Any medical care administered for my child will be in accordance with Florida Statute 743.064. As such,

only a licensed physician will render medical care and only after it has been determined that I cannot be

immediately reached by telephone at the telephone number provided below.

I authorize any HOJ representative to select a medical doctor and/or insurance-appropriate hospital for the

purpose of diagnosis or treatment of the above named minor.

List of restrictions: ______________________________________________________________

[6] Application of Authority

I understand that this release and authorization applies to HOJ, as well as its successors, licensees, agents,

employees, affiliates, and assigns.

[7] Governing Law

I agree that the laws of the State of Florida govern this Release and Authorization Form.

I have read the foregoing Release and Authorization Form, and I give my express consent.

I will not revoke my consent.

I UNDERSTAND THIS AGREEMENT WILL REMAIN IN EFFECT UNTIL THE DATE MY

MINOR CHILD REACHES THE AGE OF MAJORITY.

Name of Parent or Guardian______________________________________________________________

Signature of Parent/Guardian_____________________________________________________________

Street Address_________________________________________________________________________

City, State, Zip Code____________________________________________________________________

Area Code/Telephone Number___________________________________

JAX1024638_1

We inspire, equip, and mobilize people to take action that changes our world

6817-1902 Southpoint Parkway · Jacksonville, FL 32216 · T 904.332.6767 · F 904.332.6722 ·

Minor Volunteer Release And Authorization To Treat Form Page 2