Form 3: Medical Treatment Authorization Form (Minor Child) (Page 2 of 2) in pdf

Form 3: Medical Treatment Authorization Form (Minor Child) Page 2

2 of 2

and on behalf of Student. I further understand and acknowledge that no warranty is made as to

the results or outcome of any medical treatment or care provided to or for the benefit of Student.

I hereby agree to indemnify and hold harmless LearnServe and its directors, officers,

employees, volunteers, contractors, agents and assigns, together with my agent hereunder,

from and against any liability as a result of any medical treatment or care provided to or for the

benefit of Student pursuant to my agent’s actions authorized hereby.

This authorization is effective through: January 1, 2017.

________________________________________ ___________________________________

Parent or Guardian signature

Witness

________________________________________ ___________________________________

Parent or Guardian signature

Witness

This Medical Treatment Authorization Form (Minor Child) was sworn to and subscribed

before me by _____________________________________________________________, and

_____________________________________________________________, the Parents or

Legal Guardians of ___________________________________________________________,

a minor child, this day of __________________________________________________ [date].

_____________________________________

__________________________________

Notary Public

Date commission expires

(SEAL)

LearnServe Abroad 2016

Form 3: Medical Treatment Authorization Form (Minor Child)

Form 3: Medical Treatment Authorization Form (Minor Child) Page 2