PARENT PERMISSION AND MEDICAL TREATMENT CONSENT FOR MINORS
(to be completed by parent)
This form will enable your child to participate in out-of-center activities and transportation services. It is our policy to contact parents in case of an emergency and the information contained on this form will help us to reach you quickly. The medical authorization will prevent delay of treatment for your child in the event that you cannot be reached in an emergency. We use the emergency facilities of Theda Clark Regional Medical Center or the nearest emergency facility for out-of-town activities.
Youth Go Summer Shuttle Transportation Permission Slip.
Your child has expressed interest in Youth Go attending Youth Go’s Summer Programming. We are open for youth entering 5th-8th grades Mondays-Wednesdays 3:00pm-5:30pm and Fridays from 3:00pm-8:00pm. We are open for youth entering 7th-12th grades Monday-Thursday 6:00pm-10:00pm and Fridays from 3:00pm-8:00pm. Programming consists of structured activities such as arts and crafts and games, or use center recreation equipment such as computers, video games, and pool tables. Youth will be supervised by professional adult youth workers.
Transportation will be provided at the following sites during the summer.
Mondays 3:00/5:30/9:00 at Coolidge Elementary
Tuesdays 3:00/5:30/9:00 at Taft School
Wednesdays 3:00/5:30/9:00 at Memorial Park
Fridays 3:00/7:30 at Washington Park
Sites are subject to be cancelled or changed if there is no youth participation. Please be sure to call Youth Go at (920) 722-1435 with any questions or to confirm that sites listed are still in operation before sending your child. If Youth Go is closed due to inclement weather or a holiday, the vans will not be running.
Detach and return to Youth Go
***I give my permission for ____________________________ to participate in the program outlined above, and receive transportation through Youth Go. I will not hold Youth-Go, Inc., staff members or any of its representatives liable for any accident or injury. I understand that if my son/daughter violates any of the rules outlined above, I will be informed and expected to make any arrangements necessary for his/her immediate return home.
Special health problems:__________________________________________________________
Insurance Company ___________________________Policy #'s___________________________
Family Physician_____________________________Phone______________________________
If a parent cannot be reached, contact:
Name_______________________________________Phone_____________________________
I hereby authorize the treatment, administration of anesthesia and surgical treatment(s) for my minor child.
______________________________________________________________________________
(Name of Child)
in the event of a medical situation occurring during my absence or when the hospital or physician(s) are unable to contact me. This authorization extends to any hospital and both physician and nursing personnel within the hospital as well as any physician where treatment is rendered in the physician's office.
_________________ __________________________________ _______________________
Date Signature of Parent or Guardian Home Phone Number
_______________________
Work Phone Number