Parent Permission and Release of Liability

PARENT PERMISSION AND RELEASE OF LIABILITY

Child Name: Date of Birth:

Social Security #: Grade:

Address:

City: State: Zip:

Home Phone: Work Phone:

Parental Consent:

(I) (We), the undersigned, parent(s) of minor, do hereby consent to said Minor participating in (explain activity) conducted by: .

Authorization of Consent to Treatment

(I) (We), the undersigned, parent(s) of , minor, do hereby designate hereinafter "Agent", for and on behalf of said minor, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital, during all times that the Minor is in the presence of said Agent.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable.

HIPAA Release Authority.

My agent shall be treated as I would be with respect to my rights regarding the use and disclosure of my child's individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160 through 164. I authorize any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc. or other health care clearinghouse that has provided treatment or services to my child, or that has paid for or is seeking payment from me for such services, to give, disclose and release to my agent, without restriction, my child's individually identifiable health information and medical records relating to any past, present or future medical or mental health condition, including all information relating to the diagnosis of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. The authority given my agent shall supersede any other release that I may have made with my child's health care providers to restrict access to or disclosure of my child's individually identifiable health information.

This authority shall remain in effect through the day of , unless sooner terminated in writing.

Release of Liability

shall indemnify, hold free and harmless, assume liability for, and defend , its agents, servants, employees, officers, and directors from any and all liability for personal injury or property damage and costs and expenses including but not limited to, attorney's fees, reasonable investigative and discovery costs, court costs, and all other sums for any claim or action founded thereon, arising or alleged to have arisen out of .(child's name) use of the real or personal property belonging to or used by Agent while Minor is in the presence of Agent.

ADDENDUM TO PARENT PERMISSION AND RELEASE OF LIABILITY

Home Phone: Work Phone:

Other phone number:

Legal Guardian: Phone:

Other Emergency Contact: Phone:

Family Doctor: Phone:

Insurance Co.:

Insurance Policy Name and #:

Known Medical Conditions:

Medications?

Allergies?

Last Tetanus Immunization Date:

Will You Allow Blood Transfusions? (check your response) Yes No

Other Comments: