Limited Power Of Attorney And Release printable pdf download

LIMITED POWER OF ATTORNEY AND RELEASE

Terms not otherwise defined in this Limited Power of Attorney and Release (this “POA”) shall have the meanings

ascribed to them in that certain Master Enrollment Agreement between the Undersigned and FAA as this POA forms part of

the Master Enrollment Agreement. This durable power of attorney is not terminated by subsequent incapacity of the

Undersigned except as provided in chapter 709, Florida Statutes.

NAME OF STUDENT: __________________________________

MEDICAL AUTHORITY AND RELEASE

In order to comply with the policies of Holmes’ Regional Medical Center and any other hospitals, physicians, and

other health care provider requirements, the Undersigned are requested to sign this POA and return it to FAA as soon as

possible. The Undersigned, on behalf of the Parents and the Student, hereby provide this POA to authorize representatives of

FAA to take the actions described herein to save time should, in the unlikely event, the Student require medical treatment.

By this POA, the Undersigned hereby appoints FAA and any representative of FAA designated by such entity, to act

as the Parents' attorney-in-fact and in such Parents' stead with respect to the medical care and custody of the Student in such

Parents' physical absence. The Undersigned hereby authorize FAA personnel to transport the Student to and from medical

appointments, as necessary, and agree and acknowledge that personnel may NOT be available to remain with the Student at

all times in the “waiting room” or during periods of actual medical treatment. During such times, the Student has the

Undersigned’s permission to wait without FAA supervision until such time as he or she receives treatment by the appropriate

medical personnel. The representative of the FAA as the Parents' attorney-in-fact shall be empowered to act in the Parents'

stead and with respect to all matters concerning the provision of emergency medical treatment for the Student, including, but

not limited to, the power to: execute all consents for provision of medical services, medication or surgery; execute all

necessary documents for admission to medical institutions or any other documents or records necessary to obtain emergency

medical treatment for the aforesaid Student. All acts performed by the designated attorney-in-fact pursuant to this POA shall

bind the Undersigned. All health care providers shall have the right to rely on this document. Additionally, the Undersigned

hereby authorizes FAA to execute any and all insurance department assignments for hospitalization or medical expenses. The

Undersigned further agrees, should the insurance proceeds be insufficient to cover the entire hospital and medical costs and

expenses, the Undersigned shall be jointly and severally responsible for payment of the difference, and in the event that such

costs and expenses are not covered by insurance, the Undersigned shall be jointly and severally responsible for the entire bill.

The Undersigned hereby confirms all acts of my/our attorney -in-fact pursuant to this POA. This POA shall be

effective upon execution and all powers conferred by this instrument shall remain in full force and effect during all times in

which the Student is enrolled in or is in residence at FAA. A photocopy of this POA shall be as v alid as the original for all

purposes. THE UNDERSIGNED, ON BEHALF THE PARENTS AND THE STUDENT, HEREBY RELEASE , WAIVE

AND FOREVER DISCHARGE FAA and all of its parent company, affiliated and subsidiary companies, agents, employees,

shareholders, officers, directors, independent contractors, volunteers, successors and assigns (collectively the “FAA Parties”)

of and from any and all claims, demands, actions, causes of action, proceedings, lawsuits, liabilities, obligations, awards,

judgments, fines, assessments, penalties, injuries, death, property damage, wrongful death, loss of wages, loss of consortium,

wrongful death, loss of earning capacity, loss of profits, debts, sums of money, contracts, controversies, agreements,

promises, damages, costs and expenses (including attorney fees) of any nature whatsoever, in law or in equity, which

hereinafter may be obtained or asserted by anyone or incurred by the FAA Parties (or any one (1) or more of them) which is

in any way connected with FAA providing any medical consents for treatment or otherwise exercising any authority pursuant

to this POA and this release shall include and apply to any acts or omissions or negligence by the FAA Parties.

Please Note: All medications the Student is taking and any allergies and/or medical conditions which the Student has must

be listed on the Student Health & Personal Information Disclosure and/or the Authorization for Prescription and/or Non -

Prescription Medication.

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Limited Power Of Attorney And Release

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