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Spring Registration - January 5th-8th Spring 2025 Session Dates: Feb 13 - April 24 Snowball Dance - January 3rd, 7:00-10:00
 

Emergency Medical Form

indicates a required answer

Learning Tree Homeschool Group Emergency Medical Authorization

Purpose: To enable parents and guardians to authorize emergency treatment for children who become ill or injured while participating in The Learning Tree Homeschool Group classes and activities when parents or guardians cannot be reached.

Hold Harmless Agreement
I also understand that participation in The Learning Tree Homeschool Group classes and activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release The Learning Tree Homeschool Group, Reynoldsburg Nazarene Church, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation. I acknowledge and agree to Hold Harmless those individuals and organization noted above.
1. *

Signature of Parent/Guardian
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

 

Child Information:
Please complete for each child. Under Basic Medical Information please include allergies, medications regularly taken, or physical impairments to which a physician should be alerted. If none, write NONE.
2. *

Child's Name and Basic Medical Information:
 
3. 

Child's Name and Basic Medical Information
4. 

Child's Name and Basic Medical Information
5. 

Child's Name and Basic Medical Information
6. 

Child's Name and Basic Medical Information
7. 

Child's Name and Basic Medical Information

 

Guardian Contact Information:
8. *

1st Contact Name
9. *

1st Contact Relationship
Mother Father
Grandmother
10. *

1st Contact Phone Number
11. 

2nd Contact Name
12. 

2nd Contact Relationship

 
Mother Father
Grandmother
13. 

2nd Contact Phone Number
14. 

Physician Name
15. 

Physician Phone Number
16. 

Dentist Name
17. 

Dentist Phone Number
18. 

Preferred Hospital

 

Consent: You must sign Part 1 OR Part 2
19. 

Part 1 – Concent

I hereby grant consent that in case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider noted above or selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for purposes of medical evaluation and follow-up and communication with the participant’s parents or guardian.
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
20. 

Part 2 — Refusal to consent
I do not give my consent for emergency treatment of my child while participating in The Learning Tree Homeschool Group activities. In the event of illness or injury requiring emergency treatment, I wish that no action be taken. I acknowledge that by refusing consent, I may not leave the building or other event under any circumstances without my child(ren).
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.