Overnight Stay Emergency Information/medical Release/liability Waiver Form printable pdf download

Overnight Stay Emergency Information/medical Release/liability Waiver Form

OVERNIGHT STAY

EMERGENCY INFORMATION/MEDICAL RELEASE/LIABILITY

WAIVER FORM

This form is necessary for any prospective student staying overnight in a Scripps College residence.

Please complete both pages of this form and bring it with you to campus. The prospective student will

not be allowed to stay overnight without this form signed by a parent or guardian. Please fill out the

requested information completely and list any additional information that may be important should an

illness or injury occur.

PARTICIPANT INFORMATION

Student’s Name_____________________________ Date of Birth______________________

Home Address :

Home Phone Number_______________

__________________________________________

__________________________________________ Cell Phone Number ________________

FAMILY INFORMATON/EMERGENCY CONTACTS

Parent/Guardian Name________________________________

Relationship to Student________________________________

Home Address (if different from above)

_________________________________

Home Phone Number (if different from above)

_________________________________

Cell Phone Number

_________________________________

Place of Employment

_________________________________

Work Phone Number

_________________________________

Additional Emergency Contact

Name________________________________

Relationship to Student________________________________

Phone Number ________________________________

MEDICAL TREATMENT CONSENT:

In the event that neither I nor the additional designated

emergency contact can be reached, I authorize and consent to medical, surgical, hospital care, treatment

and procedures which is/are deemed immediately necessary by the treating physician to safeguard my

child’s health.

_______________________________

________________________

Parent/Guardian’s Signature

Date

_______________________________

Parent/Guardian’s Printed Name

Overnight Stay Emergency Information/medical Release/liability Waiver Form