Waiver Notice and Medical Authorization Form

Print Article Print Email Article Email to a friend

 

If your child is carpooling with a family other than your own or another family has been put in charge over your child for a CHEVA event or activity, we would like those members to fill out a Waiver Notice and Medical Authorization form. You may print it and then please fill it out. The CHEVA member in charge of your child will keep the Waiver Notice and Medical Authorization Form with them during the event or activity they are participating in.

 

Thank You,

The CHEVA Board

 

Christian Home Educators of the Visalia Area

Waiver Notice and Medical Authorization Form

2008-2009

 

 

 _______________________ (“Participant”) has my permission to participate in CHEVA activities or activities planned by CHEVA members. This waiver notice and medical authorization will remain in effect from (date/time)______________________to (date/time)_________________________ or, until cancelled in writing by the Participant’s parent or guardian. 

In the event of illness or injury, I do hereby consent to whatever x-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the hospital furnishing health care services.

 

I promise to indemnify, defend and hold the CHEVA organization, its officers and volunteers, harmless from any and all liability or claims, which may arise out of or in connection with my child’s participation in the youth activities or the rendering of health care services pursuant to the above medical authorization.

I fully understand the participants are to abide by all rules and regulations governing conduct during the youth activities and those principles consistent with the mission and purpose of CHEVA.  Any violation of these rules and regulations may result in that individual being sent home at the expense of the participant’s parent(s)/guardian(s).

 

I am the parent/guardian of the participant and I represent that I have the custody and authority necessary to grant the above permission, waive claims and authorize medical treatment for participant.

 

Parent/Guardian Signature: _____________________________________ Date: __________________

 

Address: ____________________________________________ Phone: _________________________

 

_________________________    ______________________     ________________________________

Medical Insurance Carrier              Policy Number                           Emergency Authorization Phone #

 

 

 

In the event of an emergency, please notify: _______________________Phone: ___________________

 

Address: ____________________________________________Relationship: _____________________