Emergency Medical Authorization

Emergency Medical Authorization Form

Client Information

Client Name(Required)
Client Date of Birth(Required)
Physician's Name(Required)

Emergency Contact

Note: In the case of an emergency every effort will be made to notify parent/guardian. In the case we are not able to reach those individuals, please include an emergency contact.
Emergency Contact Name(Required)
Participation at St Croix Therapy (SCT) involves elements of risk to participants. In consideration of my being allowed to participate at St Croix Therapy, located at 742 Sterbenz Dr., Hudson WI, the participants and their parent(s)/guardian(s), for themselves and their families, heirs, administrators, estates, and executors, voluntarily agree to assume all inherent risks incidental to St Croix Therapy, and agree that St Croix Therapy, its members/owners, employees, agents, sponsors, volunteers, instructors, the owners of the host site, and their successors and/or assigns (“SCT”), are not liable for, and I/we hereby release SCT from, any and all claims for cost, damages, death and/or injury to the fullest extent allowed by law resulting from those participating at St Croix Therapy, even if arising from ordinary negligence of SCT. Participants and/or visitors agree to observe all rules of St Croix Therapy.
In the event of any medical emergencies, I authorize St Croix Therapy to take whatever actions it deems necessary (including transport to medical service providers), and I agree to assume full responsibility for all cost associated therewith. I have read, fully understand (including that I am giving up legal rights/remedies which may be available to me), and voluntarily agree to the above medical authorization and waiver.

Responsible Party Information (Client or Parent/Guardian)

Name(Required)
Name(Required)