AUTHORIZATION FOR MEDICAL CARE AND MEDICAL RELEASE-CGAUX-10
(COMPLETE THIS FORM ONLY FOR SELECTEE)
PRIVACY ACT STATEMENT: In accordance with 5 USC 552 a(e)(3), the following
information is provided to you when supplying personal information to the
United States Coast Guard.
1. Authority which authorized the solicitation of the information:
14 USC Sec 182.
2. Principal purpose(s) for which information is intended to be used:
to determine eligibility to participate in the Academy Introduction
Mission Program at the United States Coast Guard Academy.
3. The routine uses which may be made of the information:
Provide information, address and scholastic information of all applicants
to the Academy Introduction Mission Program for the Coast Guard
Auxiliary for record keeping, statistical information and future contacts.
4. Whether or not disclosure of such information is mandatory or voluntary
(required by law or optional) and the effects on the individual, if any,
of not providing all or any part of the requested information will
prevent the selection of the person to participate in the Academy
Introduction Mission Program at the United States Coast Guard Academy.
I (We), the undersigned, am (are) the parent(s) and/or legal guardian(s) of the
person of
, a minor, being under the age of eighteen (18) years. I
(We) have specifically granted my (our) said child permission to attend the
Coast Guard Auxiliary Academy Introduction Mission Program, (Project AIM), to
be held at the U.S. Coast Guard Academy in New London, Connecticut from
July 19
to
July 19
. To the best of my (our) knowledge
and belief my (our) child has no mental or physical defects, diseases or
impairments, and during such program he/she may engage in physical activities,
including drills, exercises and sports.
In the event my (our) said child,
, should become ill or injured
while participating in this program including the period of time while my (our)
said child is traveling from his/her place of residence to the U.S. Coast Guard
Academy, while at the U.S. Coast Guard Academy, and returning from the U.S.
Coast Guard Academy to his/her place of residence, I (We) hereby authorize
medical personnel, including trained nurses and "paramedics", to administer
drugs, medication, blood and medical treatment, to include emergency first aid
and surgery, should such be necessary in the opinion of said medical personnel,
to protect the life, health or safety of my (our) said child. All decisions
concerning medical treatment of all types may be made by such personnel.
In the event of an emergency I (We) can be contacted at the following:
Telephone number(s) with area code(s)
and/or address(es)
I (We) further agree any and all medical treatment deemed to be necessary and
appropriate, in the opinion of such medical personnel, may be undertaken
without notification to me (us). I (We) further represent and agree that in
the exercise of the discretion in selection of medical facilities, medical
personnel, the U.S. Coast Guard, the U.S. Coast Guard Auxiliary and the
officers, members, personnel and employees thereof, are hereby released,
indemnified and held harmless from any loss of liability they, or any of them
may incur or suffer by virtue of acts or omissions in pursuance of the premises
herein set forth. I (We) further agree to reimburse the said U.S. Coast Guard,
U.S. Coast Guard Auxiliary and the officers, members, personnel and employees
thereof, for any and all costs and expenses they, or any of them, may incur, in
connection with such medical treatment.
Medical and Hospitalization coverage insurance, which includes coverage of my
(our) said child, is in force and effect, being policy(ies) Number(s)
Written by
(Insurance Company(ies)(If none, state "None").
I (WE) HAVE READ AND UNDERSTAND THE AGREEMENT HEREIN CONTAINED:
Witness my (our) hand(s) this
day of
19
Father
Mother
Guardian
STATE OF
COUNTY OF
ON THIS, the
day of
19
BEFORE ME, the undersigned authority, personally appeared
known to me to be the person(s) whose name(s) is (are) subscribed on this
instrument and who signed the same in my presence and (s)he (they)
acknowledged to me that (s)he (they) executed the same as their free act
and deed and that the same are true and correct.
(SEAL)
NOTARY PUBLIC
(STATE)
(COUNTY)
ANSC 7049
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