Authorization of Medical Treatment
I, legal guardian and or parent of the aforementioned minor, hereby authorize and give my consent that in my absence and ability to be reached or be present that the above named minor be admitted to any medical facility for diagnosis and treatment. In the event of an emergency I authorize the transportation of my child via ambulance and any and all medical treatment by ambulance staff and all emergency personnel. I hereby request and authorize any duly licensed medical staff to perform any and all medically necessary procedures on the above minor. I hereby authorize that in my absence or inability to be reached that Crosswalk Teen Center and or its representative be granted the authority to make any and all necessary medical decisions (using best judgment and upon advice of such medical or emergency personnel) for my minor child and hereby agree to hold Crosswalk Teen Center and/or its personal representatives, agents, assigns and/or directors harmless for the resulting consequences of such decisions.
I recognize that as a result of medical treatment and care costs may be incurred. I hereby recognize and acknowledge any medical payments and or costs for such medical treatment incurred, including but not limited to deductibles, medical services, prescriptions and co-payments, are my responsibility. I agree that under no circumstance will I seek any contribution from Crosswalk Teen Center, their insurer or hold them responsible for any costs as a result of medical expenses occurred for treatment.
I, legal guardian and or parent of the aforementioned minor, hereby authorize and give my consent that in my absence and ability to be reached or be present that the above named minor be admitted to any medical facility for diagnosis and treatment. In the event of an emergency I authorize the transportation of my child via ambulance and any and all medical treatment by ambulance staff and all emergency personnel. I hereby request and authorize any duly licensed medical staff to perform any and all medically necessary procedures on the above minor. I hereby authorize that in my absence or inability to be reached that Crosswalk Teen Center and or its representative be granted the authority to make any and all necessary medical decisions (using best judgment and upon advice of such medical or emergency personnel) for my minor child and hereby agree to hold Crosswalk Teen Center and/or its personal representatives, agents, assigns and/or directors harmless for the resulting consequences of such decisions.
I recognize that as a result of medical treatment and care costs may be incurred. I hereby recognize and acknowledge any medical payments and or costs for such medical treatment incurred, including but not limited to deductibles, medical services, prescriptions and co-payments, are my responsibility. I agree that under no circumstance will I seek any contribution from Crosswalk Teen Center, their insurer or hold them responsible for any costs as a result of medical expenses occurred for treatment.