Permission to treat form

Permission to Treat:
I hereby authorize and give my consent to any licensed health professional to perform upon or
administer to 

any reasonable, necessary treatment.

In the case of a psychiatric and/or psychological emergencies involving psychological treatment,
parental notification for treatment beyond that responsive to the emergency will be requested. This
authorization is intended to include emergency treatment, immunizations, injections, and minor
operations and procedures. I also give permission to administer whatever anesthetic may be necessary
or advisable during medical or surgical procedures. I agree to assume all costs related to such treatment.
I authorize my insurance company to pay benefits to any licensed health service provider. Also, I
authorize the disclosure of medical information to my insurance company for the purpose of this claim.
This permission is only valid while the student is attending The Harvard Debate Council Summer
Workshops.

Release of Liability:
In consideration of The Harvard Debate Council Summer Workshops granting the student permission to
participate in The Workshop, I hereby assume all risks of his/her person that may result from any
Workshop activity.
As parent or guardian, I do hereby release.