In the event emergency medical aid/treatment is required due to illness or injury while participating in a KALEIDOSCOPE OF WNY, INC. activity, or while being on the property of the agency, I authorize KALEIDOSCOPE OF WNY, INC. to: 1. Secure and retain medical treatment and transportation if needed. 2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
CONSENT PLAN This authorization includes x-ray, surgery, hospitalization, medication, ambulance, and any treatment procedure deemed “life-saving” by the physician. This will only be invoked if my emergency contact is unable to be reached. NON-
CONSENT PLAN I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of participating in KALEIDOSCOPE OF WNY, INC. programs or while being on the property of the agency. (Form options available when you choose this)
In the event emergency treatment/aid is required, I wish the following procedures above to take place.