Consent for the Treatment of a Minor
I,
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, as parent or legal guardian of
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(a minor), hereby authorize such diagnostic, medical, or surgical treatment of such minor as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury of the minor. The attending physician, appropriate staff, and On-the-Line Specialty Camps, LLC and its employees shall not be responsible for any consequences from the diagnostic, medical, or surgical treatment and are hereby released from all claims that may arise, grow out of, or be incident to such diagnosis, treatment, or surgery if these services are performed with ordinary care and to the best of their ability.
Medical Information Related to Minor
If the following fields don't apply to you, please enter "None" or "N/A".
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Allergies:
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Current Medications:
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Pertinent Medical History:
Medical Insurance Verification
I,
, as the parent or legal guardian of the minor, hereby acknowledge that the minor is covered by medical insurance as follows:
Name of Insured:
Insurance Company:
Phone:
Employer/Group Name:
Group Number:
Insurance ID#:
Insurance Holder SSN:
By entering your name here you are providing an electronic signature which will take place of a written signature.
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Parent/Guardian Signature: *
Date:
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Participant: *
Date:
