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.
Middle School After-School Program/Transportation Permission slip.
Your child has expressed interest in Youth Go’s after School Program for youth in grades 5-8, Mondays, Wednesdays, (approx. 3:30-5:30) and Fridays (approx.3:30-8) This program consists of ½ an hour of homework help(No tutoring required on Fridays), then students may participate in structured activities such as arts and crafts and games, or use center recreation equipment such as computers, Playstation, and pool tables. Youth will be supervised by professional adult youth workers. Transportation is provided from area middle schools.(Maplewood, Shattuck and Mann) White "Youth Go" Vans will be waiting in bus loading area, directly after school.( Please allow time for possible traffic and delays) This permission slip will allow your child to be picked up after school in agency vans, and transported to Youth Go. Parents are responsible for providing transportation home at 5:30. (8:00 Fridays) If youth go will be closed, or vans will not be running, Youth will be notified in advance, so parents may make other arrangements.
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