Medical Consent to Treatment
I the undersigned parent(s) or guardian of minor named above, minro do hereby consent to an x-ray examination, anesthetic, medical or surgical treatment, diagnostic procedure or service that may be rendered to said minor under the general or specific instructions of emergency department physician from emergency medical facility or other physician rendering emergency care. It is understood that this consent is given in advance of any specific diagnosis or treatment being rendered, but is given total consent to emergency treatment as may be needed. I hereby release and agree to hold harmless the Boys & Girls Club of the Grand Rapids Youth Commonwealth, its employees, agents, and/or affiliates from and against any claim for injuries or damage that might arise out of our child�s participation in the program. This consent will continue in effect for all who may rely upon it including, but not limited to the medical facility and physician on its medical staff and the Boys & Girls Club of the Grand Rapids Youth Commonwealth, until expiration date, unless they have received written notice of revocation.
Medical Consent to Treatment
• I understand that the Boys & Girls Club of the Grand Rapids Youth Commonwealth does not take my responsibility for lost, missing, or damaged items. It is recommended that personal belongings be left at home and all bikes are properly locked in the designated area.
• I understand that the Boys & Girls Club of the Grand Rapids Youth Commonwealth reserves the right to suspend my child from Club activities if my child exhibits poor behaviors. It is my responsibility to meet with the Unit Director or Site Supervisor to discuss any matter of concern on either the Boys & Girls Club part or mine.
• Club hours of operation are established for each program site. Failure to arrange timely transportation for my child to and from Club property may result in a service charge.
• I understand the Club is closed on the following holidays or their recognized day: New Years Day, Memorial Day, 4th of July, Labor Day, Thanksgiving Day, Christmas Eve, and Christmas Day and from time to time other days which will be posted in advance.
• I understand that if my child is in the 1st – 5th grade I am required to attend a parent orientation before my child can become a member and receive his or her card.
• I understand that the Boys & Girls Club of the Grand Rapids Youth Commonwealth operates their Club sites with an open door policy. 1st – 5th grade members are not allowed to leave the building unless going home for the day. Members in the 6th – 12th grade are allowed to leave the building.
