Parent’s Authorization

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Children’s Medical Rehabilitation Program

Parent’s Authorization for Treatment

Authorization for Treatment – Parents

 

 

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  • The undersigned consents to the guardianship of said child/children by Linda A. Greene of the United States of America or some suitable person approved by Linda A. Greene of the United States of America so that said child/children have a legally appointed person to provide care, support, maintenance, education and medical care for such child/children while in the United States of America.
  • The undersigned reserves the right to check on the status of said child/children from time to time. The undersigned does not hold and/or claim any liability against IMPACT WITH HOPE and/or Linda A. Greene, and voluntarily enters into the Authorization for Treatment Consent.
  • 1. To make decisions in its sole discretion regarding legal and practical steps necessary to satisfy immigration requirements of all involved countries which will enable the child to immigrate to the United States of America for the purpose of obtaining medical treatment, including making decisions in it sole discretion regarding the matter, timing and payments for travel arrangements for the “child.” IMPACT WITH HOPE will negotiate for hospital, physician and other services, but cannot assure the outcome of the treatment. To make necessary arrangements for medical or surgical care of the child and to give all required consents in connection with that care. Further, it is understood by the undersigned that the medical institution or such other hospital as selected by IMPACT WITH HOPE and the hospital’s associated medical support personnel, will be providing primary medical treatment for the child.
  • Accordingly, the undersigned hereby authorizes and appoint(s) Linda A. Greene, RN Ph.D., President/CEO of IMPACT WITH HOPE, to perform any and all of the following acts, commitments or agreements:
  • 2. Transportation is from the city of departure to city of treatment and return for the patient, if living, and the parent(s) and/or guardian(s) if his/her presence was indicated.
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  • I CERTIFY THAT I HAVE READ AND UNDERSTOOD ALL THE INFORMATION SET FORTH IN THIS FORM AND THE ANSWERS I HAVE FURNISHED ON THIS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT ANY FALSE OR MISLEADING STATEMENT MAY RESULT IN THE PERMANENT REFUSAL OF THE CHILD’S APPLICATION.
  • I CERTIFY THAT I HAVE READ AND UNDERSTOOD ALL THE INFORMATION SET FORTH IN THIS FORM AND THE ANSWERS I HAVE FURNISHED ON THIS FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT ANY FALSE OR MISLEADING STATEMENT MAY RESULT IN THE PERMANENT REFUSAL OF THE CHILD’S APPLICATION.
 

Verification