Medical Treatment Authorization Form
This form grants temporary authority to a designated adult to provide and arrange for medical care for a minor in the event of an emergency, where the minor is not accompanied by either parents or legal guardians, and it may not be feasible or practical to contact them. This form should be in the possession of the event leader or designated adult.
Minor
Full Legal Name: _______________________________________________________________________________ Home Address: _____________________________________________________________________________________
Date of Birth: _____________________Gender: (circle one) Female/Male/Prefer not to say
Mother’s Name: ______________________________ Home or Cell Number: ________________ Father’s Name: ______________________________ Home or Cell Number: ________________ Emergency Contact: (if parent is not available)
__________________ ___________________________ Phone: _______________________________
Parent e-mail address(es): ______________________________________________________________
Information for Medical Treatment
Physician’s Name and Location of Practice: _________________________________________
Physician’s Phone Number: _____________________________________
Medical Insurer/Health Plan: _____________________________ Policy Number: __________
Allergies to Medications: __________________________________________________________________________________________________________________________________________________________________________
Medications*: __________________________________________________________________________________________________________________________________________________________________________
Please note all conditions for which the child is currently receiving treatment: __________________________________________________________________________________________________________________________________________________________________________
Note any other significant medical information or allergies: ____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________
*Prescription medication MUST be in pharmacy labeled containers. -OVER-
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S) AND RELEASE OF LIABILITY
I do hereby state that I have legal custody of the aforementioned minor. I grant my authorization and consent for Agape Learning authorized adult (hereafter “Designated Adult”) to administer general first aid for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to summon any and all professional emergency personnel to attend, transport, and to treat the minor and to issue consent for any Xray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of the Designated Adult in the exercise of his/her best judgment upon the advice of any such medical or emergency personnel. I also understand and agree that my child’s participation in athletic and other activities involves the risk of injury and even death from various causes, including but not limited to accidents, fall, strenuous physical activity, dehydration, collision, weather, equipment defects, and negligence. On behalf of my child, I assume these risks. I hereby release, discharge, and hold harmless and indemnify, and covenant not to sue, Agape Learning and/or its representative including staff, employees, trustees, and volunteers. This authorization if effective through: Duration of time in Agape Learning
Parent/Legal Guardian Signature: _____________________________________________________________________
Printed Name: ______________________________________________________
Parent/Legal Guardian Signature: _____________________________________________________________________
Printed Name: ______________________________________________________
Date Signed: ________________________________________________________