Participant Signature Date Sample Clauses

Participant Signature Date. Agreement

Participant Signature Date. IMAGE/VOICE PERMISSION MEDICAL EMERGENCY NOTICE

Participant Signature Date. As Parent and/or Legal Guardian of , I hereby agree to be bound by the above conditions and accept financial responsibility for any damages to University property caused by the above signed participant. Consent to Treatment: I, the undersl�erfa patient of St. Claire Medical Group {St. Claire Regional Family Medicine, St. Claire Pediatrics, St. ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, St. ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇, St. ▇▇▇▇▇▇ Urology, St. Claire Internal Medicine� St. Claire Neurology, St. Claire Pain Management, St. Cla!re Gastroenterology, St. Claire Nephrology, St. Clalre Pu!monology, St. Claire Cardiology, St. Claire Surgery, St. Claire Podiatry, St. Clatre Oncology, St. ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Medicine, St. Qalre Wound Care, St. Claire Professional Home Services, St. Claire Telemedic!ne, and St. aaire Family Dentistry), a service of St. Claire Regional M�lcal Cent-er (Medlca) center), do hereby freely and voluntarily agree and consent to and authorize the administration and performance ofall medical treatment and. procedures, the administration of any medically accepted anesthetic, the use of any lawful drugs, and the use of any medically accepted diagnostic procedures, which, in the professional and medical judgment of my medical provider, may be considered medically necessary, advisable, or otherwise appropriate. I have the right to make decisions about my health care. I have the right to refuse medical care or surgical Interventions, and In planning for care after discharge from the Medical Center. I understand that medical care may involve risks and that no guarantees have been made concerning the results of any treatment or examination. I hereby agree and fully understand that if I should refuse treatment or leave the Medical Center without the written consent of my medical provider, I hereby release and forever discharge my medlcal providers, the Medlea I Center, and any of Its officers, employees, or staff, from any responslblllty for the consequences of such action. I agree that my conduct wlll conform to Medical Center pollcles. If I choose to smoke wh!le under the Medical Center's care, I will smoke In an approved smoking area andwaive t�e Medlcal Center from all responsibility.

Participant Signature Date. Parent or Guardian Signature (if Minor) Date Printed Name of Participant Email Address ......................................................................................................................................... Address ................................................................................................................................................... Name of Racer/Team you are supporting: ...........................................................................................

Participant Signature Date. Retirement Specialist Name/Signature Agent Number Memorandum of Understanding