[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288801-105":53,"doc-detail-288801-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","emergency-medical-treatment-authorization-form-emergency-medical-release-form","Emergency Medical Treatment Authorization Form - Emergency Medical Release Form","","Emergency Medical Treatment Authorization and Release Form for a covered person (DST Volunteer or DST Patient). It authorizes Dynamic Strides Therapy, Inc. and its designees to provide first aid and transport the covered person to the nearest emergency room if an emergency arises. The form grants permission for hospital medical staff to deliver physician-determined care in advance of any specific diagnosis, and includes release, hold harmless, and indemnification terms regarding emergency services and related claims, except gross negligence or intentional torts.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/emergency-medical-treatment-authorization-form-emergency-medical-release-form/288801/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/emergency-medical-treatment-authorization-form-emergency-medical-release-form/288801.png","ImageObject",442,249,{"name":88,"@type":89},"Putri","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who can sign this emergency medical authorization form?","Question",{"text":109,"@type":110},"The signature may be from the covered person or, if the covered person is a minor, from the parent/legal guardian. The signatory also fills in required contact and address details.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What actions does the authorization permit during a medical emergency?",{"text":114,"@type":110},"DST staff and designees may provide first aid and transport the covered person to the nearest hospital emergency room. Hospital medical staff are authorized to provide treatment deemed necessary by a physician.",{"name":116,"@type":107,"acceptedAnswer":117},"Are DST and its staff protected from liability under this form?",{"text":118,"@type":110},"Yes. The document includes a release and hold harmless covering claims related to administration of emergency medical services, with an exception for actions constituting gross negligence or an intentional tort.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},288801,1790941405,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},962085571259,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT  \nEMERGENCY MEDICAL RELEASE FORM.  \nCovered Person’s Name:   DOB:   AGE:   Covered Person is a:   DST Volunteer or   DST Patient (Check One)  \nShould a medical emergency arise, I understand reasonable efforts will be made to contact me prior to rendering treatment to the Covered Person, but that treatment will not be withheld if I cannot be reached.  \nI give my permission to Dynamic Strides Therapy, Inc. (“DST”), staff, employees, or designees to render first aid to the Covered Person should the need arise or to take the Covered Person to the emergency room of the nearest hospital. I hereby authorize the hospital’s medical staff to provide treatment which a physician deems necessary for the well-being of the Covered Person. It is understood 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 which the aforementioned physician, in the exercise of his/her best judgment, may deem advisable. I understand that it is my responsibility for the payment of any and all expenses connected with the injury and/or illness that may not by covered by my insurance.  \nRELEASE AND HOLD HARMLESS: (A) Covered Person, for himself/herself; or (B) Parent(s)/Legal Guardians(s), on behalf of themselves the Covered Person, and, in the case of both (A) and (B), each of their respective heirs, further agree to and do hereby release and hold harmless Dynamic Strides Therapy, Inc. and its officers, directors, associates, employees, and agents from and against any and all liability, claims, damages, demands, causes of action, and judgments, including but not limited to those relating to personal injury and damage to or loss of property, (collectively “Claims”) that arise from or relate to the administration of emergency medical services to the Covered Person. This release and hold harmless applies to claims on tort, negligence (including the negligence of Dynamic Strides Therapy, Inc.), privacy interests, and otherwise whether now known or that may arise in the future. This release and hold harmless does not apply to claims based on action or inaction by those otherwise released and held harmless that constitutes gross negligence or an intentional tort.  \nFurthermore, I agree to indemnify Dynamic Strides Therapy, Inc. and its officers, directors, associates, employees, and agents from any suit, claim or action brought by the Covered Person, the Covered Person’s other parent and/or legal guardian (if any), and any other person related to the Covered Person in connection with this matter.  \nA copy of this consent shall serve the same purposes and have the same force, effect and authority as an original. I declare that I have completely read and fully understand the information contained in this authorization form and voluntarily accept the terms and conditions. By my signature below, I declare that I am the Covered Person or the parent/legal guardian of the Covered Person authorized to sign this form and give permission for emergency medical treatment on behalf of the Covered Person.  \n2673 E Sawyer Road • Republic, MO • 65738 Phone: 417-324-7646  \nFax: 417-627-5542  \nKCP-8309693-1  \nCovered Person (Signature):   Date:    \nIf Covered Person is a minor, Parent/Legal guardian Name (Print)    \nIf Covered Person is a minor, Parent/Legal guardian (Signature):   Date:    \nSignatory’s Home Phone Number:   Cell:    \nSignatory’s Home Address:    \nCity State Zip  \n2673 E Sawyer Road • Republic, MO • 65738  \nPhone: 417-324-7646  \nFax: 417-627-5542  \nKCP-8309693-1","cbCaikM4mY5L1wvv","https://ap.wps.com/l/cbCaikM4mY5L1wvv","pdf",138991,"English","# Authorization for Emergency Medical Treatment\n## Emergency contact and treatment permission\n## Release and hold harmless\n## Indemnification and consent acknowledgement\n## Signatures and contact information","[{\"question\":\"Who can sign this emergency medical authorization form?\",\"answer\":\"The signature may be from the covered person or, if the covered person is a minor, from the parent/legal guardian. The signatory also fills in required contact and address details.\"},{\"question\":\"What actions does the authorization permit during a medical emergency?\",\"answer\":\"DST staff and designees may provide first aid and transport the covered person to the nearest hospital emergency room. Hospital medical staff are authorized to provide treatment deemed necessary by a physician.\"},{\"question\":\"Are DST and its staff protected from liability under this form?\",\"answer\":\"Yes. The document includes a release and hold harmless covering claims related to administration of emergency medical services, with an exception for actions constituting gross negligence or an intentional tort.\"}]","Emergency Medical Treatment Authorization Form - Emergency Medical Release Form | PDF",1789633938]