I hereby give permission and/or consent to Triple Play, LLC to authorize such emergency medical care and or treatment to the above named child may require while under supervision of Triple Play, LLC. I further authorize Triple Play, LLC to administer emergency care/treatment as required until medical assistance becomes available. I also agree to pay the entire costs and fees for the treatment of the child named above.
Note: We will make every attempt to notify parents immediately in the case of an emergency. In the event of an emergency, it would be necessary to have the following information:
By checking the box below, I agree to the above permission and/or consent.
By checking the box below, I give my permission to administer/authorize the above items.
Child will only be released to custodial parents or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident, or emergency, if for some reason the custodial parent of legal guardian cannot be reached.
By clicking the "I Agree" button below, you agree to the following: