Form 3: Medical Treatment Authorization Form (Minor Child)


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Form 3: Medical Treatment
Authorization Form (Minor Child)
LearnServe Program (please circle):
Student Name:
The undersigned represents that he/she is the parent or legal guardian having custody
of the above-named Student, who is a minor child attending the LearnServe International
(“LearnServe”) program abroad identified above. In my capacity as parent or legal guardian of
Student, I hereby authorize and appoint any adult person in whose care the Student has been
entrusted as my agent to consent to any medical procedures in connection with any illness or
injury suffered by the Student, which includes but is not limited to the authority to summon any
and all professional emergency personnel to attend, transport and treat the Student, and to
issue consent for any X-ray, anesthetic, blood transfusion, medication or other medical
diagnosis, treatment or care deemed advisable by, and to be rendered under the general
supervision of, any duly authorized physician, surgeon, emergency medical technician,
paramedic, nurse, dentist, hospital or other medical professional or facility duly licensed to
practice in the jurisdiction in which such treatment is to occur or to otherwise require, withhold or
withdraw any type of medical treatment which may be rendered to the Student. My agent
hereunder shall have the same access to the Student’s medical records that I have, including
the right to disclose the contents to others. I agree to assume financial responsibility for all
expenses of any medical treatment or care provided to or for the benefit of Student.
I understand and acknowledge that there is a possibility of complications and unforeseen
consequences in any medical treatment, and I hereby assume all such risk on behalf of myself
LearnServe Abroad 2016
Form 3: Medical Treatment Authorization Form (Minor Child)


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