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Medical Authorization to Treat Form

Medical Authorization to Treat Form

Fields marked with an * are required

EMERGENCY MEDICAL AUTHORIZATION TO TREAT

Center for the Arts requests the following information so that the program staff can arrange for medical care in the event of an emergency. You are responsible for providing accurate and complete information.

GENERAL INFORMATION

INSURANCE INFORMATION

HEALTH INFORMATION

ALLERGIES

VACCINATION INFORMATION

EMERGENCY CONTACT INFORMATION

Please list emergency contacts who may be contacted in case of emergency involving your child. Each person listed should be reachable by telephone and able to make decisions on behalf of your child if a parent and legal guardian cannot be reached. If necessary, an emergency contact should be able to come to the Program site and pick up your child.

AUTHORIZATION FOR MEDICAL CARE
To the best of my knowledge, my child/participant is capable of participating safely in the Program and that any activity restrictions, allergies, and medications are listed on this form.

I give my permission to Program staff to provide routine first aid care and in the event of serious illness or injury, I give Program staff permission to seek and authorize emergency medical treatment. I agree to indemnify and hold harmless Center for the Arts of Greater Manassas/Prince William County, Inc. and their officers, employees and agents, from any claim, damage, liability, injury, expense, or loss, including defense costs and attorney's fees, arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical expenses that may derive from any injuries to my child that may occur during his/her participation in this Program.

I understand and acknowledge that my failure to disclose relevant information may result in harm to Participant and/or others during this Program. By signing my name, I represent that I have provided all materials and important information to the Program pertaining to Participant's medical, mental and physical condition and that it is accurate and complete. I agree to notify the Program of any changes in mental, physical or medical condition before the Program begins.

Signature here. 

Signature here.