Authorization for Emergency Medical Treatment 2009-2010 Season
Parents: This form, signed by you, authorizes emergency medical or dental treatment for your minor child in case of necessity. It authorizes those persons of supervision, or their agents to act for you, regarding said treatment. AS THE PARENT(S) OR LEGAL GUARDIAN OF THE MINOR CHILD NAMED BELOW, I HEREBY GIVE CONSENT FOR SAID CHILD TO RECEIVE ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN OR DENTIST. THIS AUTHORIZATION INCLUDES, BUT IS NOT LIMITED TO, ANY X-RAY EXAMINATION, ANESTHETIC, MEDICAL, DENTAL, OR SURGICAL DIAGNOSIS OR TREATMENT, AND HOSPITAL CARE RECOMMENDED FOR THE WELL-BEING OF THIS CHILD.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required. It is given to provide authority and power on the part of the licensed medical or dental practitioners to give, and we do hereby give specific consent to any and all such diagnosis, treatment or hospital care which the physician or dentist in his best judgment may deem advisable. I/We further agree to hold any hospital, doctor, dentist or their representatives free and harmless from any liability arising out of the use of this authorization.
A copy of this authorization for care shall be as valid as the original.
