SILVERTHORNE ADULT DAY PROGRAM PERMITS

 

 

            I give the staff of Silverthorne Adult Day Program permission to transport to a local hospital emergency room for treatment in the event that a medical emergency should arise while in attendance at the day program or on an outing sponsored by the center. I understand that the participants being transported for emergency medical treatment is financially responsible for any costs incurred for such transportation and treatment. If the medical emergency occurs in the Salem are, I would prefer transpiration to ________________________hospital for needed emergency care. (The Salem Rescue Squad agrees to transport to either Veteran’s Administration, Holy Family, Lawrence General Hospital or Parkland Hospital unless the medical needs or hospital situations dictate otherwise.)

 

            I understand that the staff of the Silverthorne Adult Day Program will make every effort to notify the participant’s designated responsible agent of any event requiring emergency treatment as soon as possible after emergency medical personnel take over the care of the participant.

 

 

MEDICAL TREATMENT

            I agree to medical treatment by nursing staff approved by the Silverthorne Adult Day Program if such treatment has been ordered, in writing by the participant’s physician and is included in his/her treatment plan in use by the day center.

 

TRANSPORTATION           

            I give permission to ride in the Silverthorne van for local outings.

PHOTOGRAPHS

            I give the staff of Silverthorne Adult Day Care Center permission to take and use photographs while participating in the day care program for promotional or program purposes.

PETTY CASH   I authorize Silverthorne to use the petty cash funds left at center solely for ________________________________________

 

Participant:______________________________________________________________

 

Agent:__________________________________________________________________

 

Staff:___________________________________________________________________

 

Date:___________________________________________________________________