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    Parental Release For Emergency Treatment Consent

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    sylvain.dalanson
    This document is an emergency treatment consent form for a minor. It authorizes the dive center/resort/instructor to seek medical treatment for the minor in case of an accident or illness. It allows a licensed physician to treat the minor in a medical emergency without delay if needed to prevent harm. The parent/guardian has read and understands the liability release and assumes the risks involved. Contact information for the parent/guardian is provided.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Parental Release For Emergency Treatment Consent

    Uploaded by

    sylvain.dalanson
    23 views1 page
    This document is an emergency treatment consent form for a minor. It authorizes the dive center/resort/instructor to seek medical treatment for the minor in case of an accident or illness. It allows a licensed physician to treat the minor in a medical emergency without delay if needed to prevent harm. The parent/guardian has read and understands the liability release and assumes the risks involved. Contact information for the parent/guardian is provided.

    Original Title

    10088 Parental Release for Emergency Treatment Consent

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    This document is an emergency treatment consent form for a minor. It authorizes the dive center/resort/instructor to seek medical treatment for the minor in case of an accident or illness. It allows a licensed physician to treat the minor in a medical emergency without delay if needed to prevent harm. The parent/guardian has read and understands the liability release and assumes the risks involved. Contact information for the parent/guardian is provided.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    23 views1 page

    Parental Release For Emergency Treatment Consent

    Uploaded by

    sylvain.dalanson
    This document is an emergency treatment consent form for a minor. It authorizes the dive center/resort/instructor to seek medical treatment for the minor in case of an accident or illness. It allows a licensed physician to treat the minor in a medical emergency without delay if needed to prevent harm. The parent/guardian has read and understands the liability release and assumes the risks involved. Contact information for the parent/guardian is provided.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    EMERGENCY TREATMENT CONSENT FORM

    www.padi.com

    I affirm I am the parent and/or legal guardian of __________________________________________________________________________.


    NAME OF MINOR

    As the parent/guardian, I hereby authorize ______________________________________________________________________, and/or its


    (DIVE CENTER/RESORT/INSTRUCTOR)

    agents, employees or assigns, to seek medical treatment for _______________________________________________________________,


    (MINOR)

    as a result of an accident or illness while under the supervision of ___________________________________________________________.


    (DIVE CENTER/RESORT/INSTRUCTOR)

    I authorize the treatment of ___________________________________________________________________________, by a qualified and


    (MINOR)

    licensed physician in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause
    disfigurement, physical impairment or undue discomfort if delayed.

    I affirm I have read the Liability Release and Assumption of Risk form, signed it of my own free will, and understand the legal conse-
    quences of signing the document.

    I have fully informed myself of the contents of this Emergency Treatment Consent Form by reading it before I signed it.

    _______________________________________________________ ________________________________________________________
    PARENT/GUARDIAN (PLEASE PRINT) DD / MM / YY

    _______________________________________________________ ________________________________________________________
    SIGNATURE OF PARENT/GUARDIAN HOME PHONE

    _______________________________________________________ ________________________________________________________
    ADDRESS WORK PHONE

    ________________________________________________________________________
    ADDRESS

    Specific medical allergies, medicine being taken or other conditions physician should be aware of (if none, please write NONE):

    ______________________________________________________________________________________________________________________

    ______________________________________________________________________________________________________________________

    Medical Insurance Company: ________________________________________________________________________________________

    Policy Number: ______________________________________________

    G PRODUCT NO. 10088 (Rev. 1/99) Version 1.1 © International PADI, Inc. 1995, 1999

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