Please list someone from the community or work. Do not use a relative.
I acknowledge that My Child, a minor younger than 18 years of age (“My Child”), has been provided with the opportunity to volunteer to serve in a Nicklaus Children’s Hospital Camp (the “Camp”).
I, the parent or guardian of My Child, do hereby consent to and authorize My Child to volunteer and provide service hours to the Camp. I hereby authorize the Variety Children’s Hospital d/b/a Nicklaus Children’s Hospital (“NCH”), through its agents or employees, to take whatever steps necessary to secure medical treatment for My Child in the event My Child appears to be, at the sole discretion of NCH, in need of such treatment while volunteering at the Camp.
Furthermore, I understand and acknowledge that by signing this authorization form, I hereby consent to the rendering of all necessary medical treatment to My Child, which may include, but may not be limited to, My Child’s admission to NCH, or other appropriate health care facility, in such institutions and at such places as NCH or other authorized emergency response service, in its sole discretion, acting through its agents or employees, deems appropriate. I authorize the agents or employees of NCH to execute whatever forms and/or actions which might be necessary to ensure complete and adequate care of My Child. I also understand and agree that I am financially responsible for payment of all charges incurred as a result of any medical treatment or emergency transportation deemed necessary.
By signing this Parental/Guardian Consent & Medical Authorization, I acknowledge and represent that: (i) I have read and understood this document; (ii) I am signing this document voluntarily and for full and adequate consideration, fully intending to be bound by the same; (iii) I am at least eighteen (18) years of age, of sound mind and body, and authorized to complete this document on behalf of My Child; and (iv) I authorize the release of medical insurance information listed below by NCH to whomever has a need-to-know. I understand that this is a legal document which is binding on me, my heirs, executors, administrators, and assigns and on those who may claim by or through me.