Emergency Medical Form
Full Name
Address
City
State/Province
Zip/Postal
Address (if different than parent / guardian 1)
City
State/Province
Zip/Postal
Country

If neither parent/guardian is available in an emergency, notify:

Emergency Medical Authorization Grant Consent

In the event reasonable attempts to contact me or second parent/guardian at the numbers listed above, have been unsuccessful, I hereby give my consent for: (1) the administration of any treatment of physician or dentist listed above, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to preferred hospital or any hospital reasonably accessible.

This authorization does not cover major surgery unless the medial opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

Waiver

I understand that the YMCA of Greater Cincinnati assumes no responsibility for injuries or illness, which my child may sustain as a result of his/her physical condition or from his/her participation in any activity of the Powel Crosley, Jr. Branch. I expressly acknowledge on behalf of myself and my heirs that I assume the risk for any and all injuries and illness, which may result from my child’s participation in these activities. I hereby release and discharge the YMCA of Greater Cincinnati, its agents, servants and employees from any and all claims for injury, illness, death, loss of damage which I, or my children, may suffer as a result of participation in these activities.

ACCEPTANCE

I acknowledge the Waiver set forth above.