Bethell Hospice Bethell Hospice Services Parental Consent Form

Bethell Hospice Services Parental Consent:

Preferred Pronoun

First Name

Last Name

Date of Birth

My child has the following medical conditions

None

Conditions

Medical Conditions

My child has the following allergies

None

Allergies

My child has the following medications (please provide details)

None

Medications

Email

Primary Parent or Guardian Information:

Preferred Pronoun (Emergency Contact)

First Name

Last Name

Relation to Client

Address Street

PO Box

City

Province

Postal Code

Home Phone

Cell Phone

Email

In the event of an emergency, if the parent/guardian is unavailable, please contact:

Emergency Contact Information:

PREFERRED PRONOUN

First Name

Last Name

Primary Phone

Secondary Phone

The mission of Bethell Hospice is to provide excellent person-centered, palliative care through partnerships within our community. Values of the organization include: Compassion, Integrity, Accountability, Excellence, Teamwork and Courage.

Family Doctor (or other professional involved in your care):

Doctor's Name

Type of Professional (i.e. Family Doctor, Care Coordinator, Social Worker etc.):

Doctor's Address

Doctor's Phone

CONSENT for Service:

I hereby give consent for my child to take part in the Bethell Hospice Community Support Programs, one on one or and/or in a group setting.

MEDICAL Emergencies:

I agree that in the event of a medical emergency, if medical treatment is required, I will be notified and my child will be transported to a medical facility or 911 will be called. A doctor has the right to insist on parental consent prior to treating a child.

PRIVACY and Confidentiality

I understand that all personal information will be treated as private and confidential as per the Personal Health Information Protection Act, 2004.
I understand that information sharing between Bethell Hospice personnel shall be for the sole purpose of providing quality service to meet my needs and those of my family. I understand that all personal information will be treated as private and confidential. Safety supersedes confidentiality when persons are at risk.

VOLUNTEERS:

I understand that volunteers are part of the Bethell Hospice team who are trained to work in specific roles and contribute to my child’s experience while enrolled in service with Bethell Hospice.

WAIVER:

I understand and accept the conditions noted above. I agree to release and indemnify Bethell Hospice or any directors, officers, volunteers, agents and employees from all claims and liability for any of the following:

Personal injury, illness, incapacity, or death that occurs, or
The loss of money, valuables and personal effects unless held in safe keeping by the Hospice
Loss of property or damage (unless intentionally committed)
Any care provided to me other than by the employees and agents of the Hospice

I agree to release Bethell Hospice along with its directors, officers, volunteers, agents and employees of all actions, claims or demands of any nature or kind arising out of, or in any way connected with the provision of services by Bethell Hospice except if claims arise from intentional or deliberately harmful or criminal actions.

FEES for Service:

I understand that the services of the community support programs are provided at no cost thanks to the generosity of donors, community partners and government funding. Financial donations, in-memoriam donations and bequests are gratefully accepted. To discuss donation opportunities, please contact the Foundation office at foundation@bethellhospice.org.

AODA Statement

Bethell Hospice is committed to providing an accessible experience in which all individuals have equal access to our services and facilities as required by the Accessibility for Ontarians with Disabilities Act, 2005

PRIMARY PARENT

GUARDIAN

PRINT Name

Dated

Please forward a copy of this completed form to the following email address for my records:

Messages sent via the internet can be intercepted. If you are concerned about providing your personal information by email or website form submission, please contact us directly at 905-838-3534 to arrange for an alternate method of communication.

For more information, please refer to our Bethell Hospice Privacy Statement.

Bethell Hospice Services Parental Consent Form

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