CONSENT FOR MEDICAL TREATMENT OF A MINOR CHILD
I herewith authorize Eastside Church of Christ staff at Eastside Church of Christ events to request and consent in writing or otherwise as requested by Union Hospital, Inc. and/or any other medical facility to any and all examinations, medical treatment and/or procedures to or for the above named minor, either on or off the premises of medical facility, as deemed advisable or appropriate by any physician or surgeon licensed to practice medicine in the State of Indiana. I understand that verbal consent will be sought using the phone numbers listed in this application.
In consideration of the acceptance of the above-named camper, I covenant and agree with Eastside Church of Christ, that I will at all times hereafter indemnify, and save harmless the said Eastside Church of Christ from all actions, proceedings, claims, demands, costs, damages and expenses which may be brought against, or claimed from Eastside Church of Christ, or which it may pay, sustain, or incur as a result of illness, accident, or misadventure to the above named camper during the period said camper is a participant in the Eastside Church of Christ.
This authorization constitutes a Power of Attorney and waiver of liability appointing the above named adult or staff of Eastside Church of Christ as Attorney-In-Fact to sign said requests and as fully thought I, myself, did so.
This is effective from the dates of July 30th 2020 through August 2nd 2020.