Check "yes" or "no" for all conditions. Please comment below with more details.
Authorization for Medical Care
This health history is correct so far as I know. The person herein described has permission to engage in all activities except as noted. I hereby give permission to the Adult-In-Charge to provide routine health care and witness prescribed medications. I consent for my child to receive such medical treatment and/or surgical procedures as are deemed necessary in the event of an emergency and to assume liability for any medical expenses involved. This authorization extends to my child’s participation in any activity sponsored by MITY. Should a medical emergency arise during my child’s participation in a MITY sponsored activity, I understand that reasonable efforts will be made to contact me or my designated alternate at the phone numbers I have given. If it is believed my child’s life or health may be adversely affected by the delay that an attempt to contact me or my designated alternate would cause, I consent to the administration of medical treatment and/or surgical procedure deemed necessary by the medical doctor and/or medical facility and the immediate administration of life-sustaining measures deemed necessary under the circumstances. This completed form may be photocopied.
Please indicate whether you are willing to have phographs of your child used for promotional and/or public information purposes, including our website and Facebook. Names are never used.
I understand and agree that I will keep YES staff informed if someone other than a parent or guardian is authorized to pick up my child at the YES program and to provide accurate information about any pick up changes.