Emergency Medical Form

indicates a required answer

Learning Tree Homeschool Group Emergency Medical Authorization

Purpose: To enable parents and guardians to authorize emergency treatment for children who become ill or injured while participating in The Learning Tree Homeschool Group classes and extracurricular activities when parents or guardians cannot be reached.

Hold Harmless Agreement
I also understand that participation in The Learning Tree Homeschool Group classes and activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release The Learning Tree Homeschool Group, Reynoldsburg Nazarene Church, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation. I acknowledge and agree to Hold Harmless those individuals and organization noted above.
1. *

Signature of Parent/Guardian
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

 

Child Information:
Please complete for each child. Under Basic Medical Information please include allergies, medications regularly taken, or physical impairments to which a physician should be alerted. If none, write NONE.
2. *

Child's Name and Basic Medical Information:
 
3. 

Child's Name and Basic Medical Information
4. 

Child's Name and Basic Medical Information
5. 

Child's Name and Basic Medical Information

 

Guardian Contact Information:
6. *

1st Contact Name
7. *

1st Contact Relationship to Child
8. *

1st Contact Phone Number
9. 

2nd Contact Name
10. 

2nd Contact Relationship to Child
11. 

2nd Contact Phone Number
12. 

Preferred Hospital
13. 

I hereby grant consent that in case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. I do not grant permission for the administration of any vaccines. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation and follow-up and communication with the participant’s parents or guardian.
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
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