PLEASE SIGN AND HAVE BOTH SECTIONS NOTARIZED
AUTHORIZATION FOR TREATMENT OF A
MINOR
This provides my permission for necessary medical treatment at a hospital or medical facility in the event of an emergency medical situation relating to my minor child, listed herein, and in the event that I am unavailable.
I hereby give my
consent to any hospital, medical facility or Professional to the administration
of whatever medical care deemed appropriate by the emergency medical staff
until I can be contacted.
Signature of
Parent/Guardian: ______________________ Date: ____________
Address:
_____________________________________ Home Phone: _______
_____________________________________________Work
Phone: ________
Name of Notary:
(please print) ______________________________
Signature of Notary
Public: _________________________________
Date:
_____________ Commission Expiration:
_________________
I hereby grant permission for ___________________________ to participate in all activities of the “Journey East Project.” This includes permission to be transported for field trips and other activities; to be interviewed and/or photographed by representatives of the media; to be mentioned in publicity releases and to respond to questionnaires designed to provide data for program evaluation, professional or academic research.
Parent/Guardian
Signature: _____________________ Date: _______________
Name of Notary:
_________________________________
Signature of Notary:
______________________________
Date:
________________ Commission Expires:
_________________