Responsibility and Medical Authorization
Commitment of Responsibility
1). I have read the excelsior! handbook, and I agree to abide by it and to be responsible for my child(ren) abiding by it. I commit myself and my family to help excelsior! maintain proper discipline, respect, a good reputation and an excellent learning environment. I also agree to be responsible for returning all music/supplies that belong to excelsior! and if I lose or damage these items, I will replace them.
2). I will make every attempt to help with fund raising in order to
i) keep tuition down
ii) be able to offer scholarships based on true financial need
iii) help excelsior! purchase needed hard assets for classes.
3). I realize that I need to volunteer to monitor a class during excelsior! or if this is a true hardship, I need to talk with the director about volunteering in some other capacity.
4). I understand that the structure of excelsior! is such that I need to be willing to be a task coordinator.
5). If I leave the CFC facility, I must be able to be contacted by cell phone in case of an emergency involving my child(ren). This cell phone number will be listed on the Medical release form and filed in the excelsior! file box. This file box will be kept under the excelsior! information table during excelsior! class times.
6). If I do not have a cell phone, the parent monitor or director has my permission to make appropriate decisions regarding my child(ren) in my absence.
7). I understand that I will be asked to sign a medical release form for my child(ren) that are on the CFC premises during excelsior! class time. This form will also be kept on file in the excelsior! file box for quick retrieval in the event that an emergency arises and I cannot be contacted.
8). By signing this Commitment of Responsibility, I understand that I am ultimately responsible for my child whether I am on the CFC premises or not.
2). I will make every attempt to help with fund raising in order to
i) keep tuition down
ii) be able to offer scholarships based on true financial need
iii) help excelsior! purchase needed hard assets for classes.
3). I realize that I need to volunteer to monitor a class during excelsior! or if this is a true hardship, I need to talk with the director about volunteering in some other capacity.
4). I understand that the structure of excelsior! is such that I need to be willing to be a task coordinator.
5). If I leave the CFC facility, I must be able to be contacted by cell phone in case of an emergency involving my child(ren). This cell phone number will be listed on the Medical release form and filed in the excelsior! file box. This file box will be kept under the excelsior! information table during excelsior! class times.
6). If I do not have a cell phone, the parent monitor or director has my permission to make appropriate decisions regarding my child(ren) in my absence.
7). I understand that I will be asked to sign a medical release form for my child(ren) that are on the CFC premises during excelsior! class time. This form will also be kept on file in the excelsior! file box for quick retrieval in the event that an emergency arises and I cannot be contacted.
8). By signing this Commitment of Responsibility, I understand that I am ultimately responsible for my child whether I am on the CFC premises or not.
excelsior!, inc., nfp, Medical Authorization
We, the undersigned parent(s) of ___________________ do hereby authorize excelsior!, a not-for-profit corporation, or its authorized representative to select any doctor, dentist, nurse, first-aid attendant, ambulance attendant, or any other person necessary to perform medical, surgical and/or dental treatment. This authorization authorizes such doctor, dentist, nurse, first- aid attendant, and/or ambulance attendant to perform whatever medical, surgical, and/or dental treatment such person feels necessary and further authorizes admissions to such medical, hospital and/or dental facility deemed necessary.
I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care.
I also understand that effort shall be made to contact the undersigned prior to rendering any treatment of the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.
I agree to reimburse excelsior! for any medical and/or related expense incurred on my behalf within 30 days of the event.
Please list any emergency/medical information that excelsior! should be aware of concerning your child.
I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care.
I also understand that effort shall be made to contact the undersigned prior to rendering any treatment of the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.
I agree to reimburse excelsior! for any medical and/or related expense incurred on my behalf within 30 days of the event.
Please list any emergency/medical information that excelsior! should be aware of concerning your child.
©2008 excelsior! inc., nfp
All rights reserved. Unauthorized use of images and content is strictly prohibited.
All rights reserved. Unauthorized use of images and content is strictly prohibited.
