Fill and Sign the Parental Form Printable

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 ______________________________________ , a minor, do hereby consent to said Minor participating in ______________________________________ (explain activity) conducted by: ______________________________________ Authorization of Consent to Treatment of Minor : (I) (We), the undersigned, parent(s) of ______________________________________ , a minor, do hereby authorize ______________________________________ , hereinafter "Agent", for and on behalf of the undersigned 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 - 1 - 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, all of my child’s individually identifiable health information and medical records regarding 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 agreement 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 authorization shall remain effective through the ______ day of ______________________________________ , 20 ______ , unless sooner terminated in writing. Release of ______________________________________ : ______________________________________ 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. Parent_____________________________________________ Date:______________ Signed Parent______________________________________________ Date:______________ Signed - 2 - 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.: ______________________________________ If None Please Check: Insurance Policy Name and #: ______________________________________ Known Medical Conditions: ______________________________________ Medications? ______________________________________ Allergies? ______________________________________ Last Tetanus Immunization? ______________________________________ Will You Allow Blood Transfusions? (check your response) Yes No Other Comments: ______________________________________ Parent_____________________________________________ Date:______________ Signed Parent______________________________________________ Date:______________ Signed - 3 -