ACP EMERGENCY WAIVER 2023-24
Authorization for Emergency Medical Care and Transportation

FORM 4 OF 4 OF ACP STUDENT REGISTRATION PACKET 
TO BE COMPLETED BY PARENT/GUARDIAN FOR EACH CHILD BEING ENROLLED IN ACP PROGRAM.

All information regarding the MPVA ACP Program can be found on our website at mpva.membershiptoolkit.com/AFTERCARE-2023-PAGE1

Parents/Guardians: Enter preferred email on the line below.
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Authorization for Emergency Medical Care and Transportation
I am the legal parent/guardian of the student named in this document; that student is a participant in the Morning/After Care Program ("ACP") at MPVA MIDDLE SCHOOL. In the event of a medical emergency, I hereby grant authorization for ACP staff or its representatives to secure emergency medical care and, if deemed necessary, to transport my child to an appropriate medical facility for treatment.

This authorization includes, but is not limited to, administering first aid, arranging for medical evaluation, treatment, hospitalization, diagnostic testing, and procedures as required by the medical personnel attending to my child. I understand that every reasonable effort will be made to contact me or the designated emergency contacts before taking such actions.

This authorization is effective from the date of form submission (timestamp) and remains valid until revoked in writing by me or the end of the 2023-24 HISD school year, whichever occurs first. 

By typing my full legal name below, as my electronic signature, I acknowledge my authorization as described in this form, above: *
Parent/Guardian Phone Number: *
Secondary Emergency Contact: Name/Phone Number/Relationship: *
A copy of your responses will be emailed to the address you provided.
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