Medical Treatment Authorization and Release of Liability



FILEWest Houston Home EducatorsTeen Group Medical Release and Information(please print clearly)Student Name: DOB: Street Address: City: State:TXZip: Home Phone: Teen Cell Phone: Father’s Contact InformationMother’s Contact InformationName: Name: Cell # Work # Cell # Work # Address if different from above: Address if different from above: Home Phone if different from above: Home Phone if different from above: Insurance Information Company: Phone # Plan/Group # Insured ID# Emergency Contact to be used during Teen Group Activities if Parents are not availableName: Relationship to Teen: Phone #’sHome: Work: Cell: MOBILEWest Houston Home EducatorsTeen Group Medical Release and Information(please print clearly)Student Name: DOB: Street Address: City: State:TXZip: Home Phone: Teen Cell Phone: Father’s Contact InformationMother’s Contact InformationName: Name: Cell # Work # Cell # Work # Address if different from above: Address if different from above: Home Phone if different from above: Home Phone if different from above: Insurance Information Company: Phone # Plan/Group # Insured ID# Emergency Contact to be used during Teen Group Activities if Parents are not availableName: Relationship to Teen: Phone #’sHome: Work: Cell: Previous Injuries/Serious Illnesses/or AllergiesCurrent Medications/Health Conditions/Learning Disabilities Medical Treatment Authorization and Release of LiabilityI hereby authorize any representative of West Houston Home Educators Teen Group to consent to medical treatment of my child in the event of an emergency (as determined by the representative). I further authorize any representative of WHHE Teen Group to render first aid to my child and/or transport him/her to a hospital and/or call an ambulance. The consent is valid and irrevocable for one (1) year from the date hereof. I further release WHHE Teen Group representatives as a group and individually from any and all liability, even their own negligence, for injuries to my child arising out of my child participating in WHHE Teen Group Activities. Signature of Parent or GuardianPRINT or TYPE name of Parent or GuardianDate signedState of Texas, County of Harris§This instrument was acknowledged before me on , 20 by Notary Public SignaturePrevious Injuries/Serious Illnesses/or AllergiesCurrent Medications/Health Conditions/Learning Disabilities Medical Treatment Authorization and Release of LiabilityI hereby authorize any representative of West Houston Home Educators Teen Group to consent to medical treatment of my child in the event of an emergency (as determined by the representative). I further authorize any representative of WHHE Teen Group to render first aid to my child and/or transport him/her to a hospital and/or call an ambulance. The consent is valid and irrevocable for one (1) year from the date hereof. I further release WHHE Teen Group representatives as a group and individually from any and all liability, even their own negligence, for injuries to my child arising out of my child participating in WHHE Teen Group Activities. Signature of Parent or GuardianPRINT or TYPE name of Parent or GuardianDate signedState of Texas, County of Harris§This instrument was acknowledged before me on , 20 by Notary Public Signature ................
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