2019 JSU4 Youth-Permission-and-Medical-Release

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PARENTAL PERMISSION AND MEDICAL AUTHORIZATION FORM

  • I give permission for my child (named above) to attend the Jump Start U4 College Tour with The Willie and Vivian Gaddis Foundation for KIDS, Columbus, OH.

    Medical Release

    I hereby authorize the Willie and Vivian Gaddis Foundation for K.I.D.S. tour leaders, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.

    Custody Release

    I further authorize Willie and Vivian Gaddis Foundation for K.I.D.S. The Willie and Vivian Gaddis Foundation for KIDS to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child back to the staff of The Willie and Vivian Gaddis Foundation for KIDS.

    Activity Release

    I give permission for my child (named above) to attend the Jump Start U4 College Tour with the Willie and Vivian Gaddis Foundation for K.I.D.S., Columbus, OH.

    Medical Release

    I hereby authorize the Willie and Vivian Gaddis Foundation for K.I.D.S. tour leaders, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.

    Custody Release

    I further authorize the Willie and Vivian Gaddis Foundation for K.I.D.S. to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to said adult.

    Activity Release

    I further give permission for my child to participate in all activities sponsored by the Willie and Vivian Gaddis Foundation for K.I.D.S., except as noted:

  • Other Emergency Contact(s)

  • HEALTH CARE INFORMATION

  • Physician

  • Section

  • Dentist

  • We love to promote our trips so that others will learn about of the program. You have received this parental consent form to both inform you and to request your permission for you and your child’s photo/image and name to be published on social media and at www.gaddis4kids.org and/or any other websites maintained, owned, and/or administrated The law requires that we ask for your permission to use information about your child. Pursuant to law, we will not release any personally identifiable information without prior written consent from you as parent or guardian. Personally identifiable information includes youth names, age, grade, and photo or image. If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to Alethea E. Gaddis – agaddis@gaddis4kids.org and such rescission will take effect upon receipt.

 

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