The following form must be printed and submitted.
It is detailed in text format below, but due to the necessary notarization, you must download the accompanying PDF to fill out and submit.
Minor’s Name _______________________________ Trip __________________________________
Last First Middle Date Country
WHEREAS, I, __________________________, wish my child, ___________________, to be a member of the Short-term Trip Program at China Call, Inc. and a member of the China Call, Inc. team, which will be traveling and staying in the USA and to and in other countries, and WHEREAS, certain circumstances and situations may occur resulting in my child’s need for medical/dental care and treatment, and further resulting in my inability to personally give consent for such care and treatment;
THEREFORE,
1. In consideration of permission for my child to participate in said program, I, _______________________, being of legal age, authorize China Call, Inc., or any agent of China Call, Inc., to act in my behalf and my child’s behalf should I be unable to do so and to consent to reasonable medical/dental care and treatment for my child, including but not limited to diagnostic test, x-ray examination, anesthesia, surgery, or other procedures which may be deemed necessary for my child’s medical well-being for the duration of the trip.
2. This consent is given in advance of any specific diagnosis, treatment, surgery, or hospital care required, but is given to provide authorization and specific consent for medical/dental treatment and care in my child’s behalf.
3. Any consent by China Call, Inc. or any agent of China Call, Inc., shall have the same force and effect as if I had personally given the consent.
4. I am aware that serious illness, requiring return by air ambulance could cost more than $10,000. I agree that I am solely responsible for any expenses that may arise from my child’s return by air ambulance or other extraordinary means.
5. I hereby release and hold harmless China Call, Inc., its officers, employees, and representatives / volunteers from all liability for personal injury, including death, as well as all property damage or loss arising out of my child’s participation in the Short-term Trip Program.
_______________________________________________ _____________
Parent/Guardian’s Signature Date
Please have this form notarized.
State of _______________________,
County of ______________________.
Before me, the undersigned, a Notary Public in and for said county and state of ______________, in the year of __________, personally appeared the identical person who executed the within and forgoing instrument, and acknowledged to me that he/she executed the same as his/her free and voluntary act and deed, for the uses and purposes therein set forth. Given under my hand and seal of office the day and year above written.
__________________________________________
Notary Public Signature Notary Public Stamp
My commission expires: ________ / ________ / __________
