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Indiana University Bloomington

Undergraduate Department

 

* Required Fields
Summer Program Medical Release Form

If you are younger than 18, you must have a parent or family member present while completing the form.

All participants must complete this section of the form.

Participant Information


*First Name: *Last Name:
*E-Mail: *Session Attending:
*Gender:      Dietary Restrictions:
 T-Shirt Size:

All participants must complete this section of the form.

Parent/Family Member Contact Information

*Parent First Name: *Parent Last Name:
*Relationship to Participant: *Daytime Telephone:
*Street Address: *Evening Telephone:
*City: *Cell Phone:
*State:   *Zip Code: *E-mail:
*Country:
 
Parent First Name: Parent Last Name:
Relationship to Participant: Daytime Telephone:
Street Address: Evening Telephone:
City: Cell Phone:
State:   Zip Code: E-mail:
Country:

Consent for Medical Treatment (minors only)

If you are younger than 18, please complete this section with a parent or family member.

If you are older than 18, please continue to Participant Medical Information.

I,   (name of parent/family member), am the parent or legal guardian of   (name of student participant) and I authorize the (name of program) to obtain emergency medical treatment of this minor by an appropriate health care professional should the need arise while he/she is attending the program.

Participant Signature:       Date: 4/18/2014

Parent/Family Member Signature:       Date: 4/18/2014

Participant Medical Information

This section must be completed by all participants.

Enter a response for each item.  If one does not apply to you, please list “none.”

*Birth Date: *Age: *Date of last Tetanus Toxoid:

*Past Health/Injuries:
*Present Health:
*Allergic Reactions:
*Present Medications:


A staff member will contact the parent or guardian for details.

Insurance Information

All participants must complete this section of the form.

Parents or legal guardians are responsible for the cost of a minor’s medical treatment.  When available, insurance information will be processed by the health facility performing the treatment; otherwise you will be contacted for payment by cash, check or credit card.

*Insurance Company: *Policyholder’s Name:
*Insurance Company Address: *Policy Number:
*Insurance Company City: Please include the identification number, benefit code, account number, etc.
*Insurance Company State:   *Zip Code:
*Insurance Company Phone: *Insurance Group Number: