Cadet Consent For Medical Treatment printable pdf download

CADET CONSENT FOR MEDICAL TREATMENT

ALL FORMS MUST BE COMPLETED, SIGNED AND RETURNED TO THE HEALTH CENTER BEFORE

CADET ARRIVES ON CAMPUS. PLEASE MAINTAIN A COPY OF ALL FORMS.

(Physical to be completed no earlier than June 1

for the incoming school year)

CADET NAME

______________________________________________________________________________________________________

(LAST)

(FIRST)

(MIDDLE)

___________________________________________

CADET SOCIAL SECURITY NUMBER

DATE OF BIRTH________________

ADDRESS

_______________________________________________________________________________________________________

(NUMBER AND STREET)

_______________________________________________________________________________________________________

(CITY)

(STATE)

(ZIP CODE)

PHONE

(H) ____________________________ (Cell) ________________________(VF email) ____________________________________

PARENT/GUARDIAN _______________________________________________________(email)_______________________________________

PHONE

(H) ____________________________ (Cell)_________________________(W) _________________________________________

PARENT/GUARDIAN _______________________________________________________(email)_______________________________________

PHONE

(H) ____________________________ (Cell) ________________________ (W) _________________________________________

EMERGENCY CONTACT (OTHER THAN PARENT/GUARDIAN) ______________________________________________________________

PHONE

(H) ____________________________ (Cell) ________________________(W) _________________________________________

RELEASE STATEMENT

I do hereby give permission for the Valley Forge Military Academy and College Health Center staff and/or consultants approved by them to treat my son/daughter on a

routine or emergency basis. I also give my permission for his/her referral to any other area hospital for evaluation and treatment as deemed necessary for his/her well being.

I also understand that should such a referral be necessary, I will be notified as soon as possible. For my student athlete, I give permission for treatment by a certified

athletic trainer and/or a sports medicine practitioner contracted by VFMA&C. I will provide a complete health and immunization record to the Health Center before

his/her arrival on campus. I understand that if these are not complete in accordance with PA state law they will be administered without further notice at VFMA&C Health

Center and at an additional cost to me. I fully understand that I am responsible for any and all expenses incurred in the medical, surgical, psychiatric, dental, and podiatric

treatment of my Cadet.

I do hereby give permission for VFMA&C Health Center to release and receive protected health information regarding my Cadet; for the purpose of but not limited to,

completion of all required medical/psychiatric records and pertaining to referrals made to medical professionals, consultants, labs, and hospitals involved in his/her care.

The Health Center may review/release pertinent medical/drug test results to VFMA&C Administration.

I give permission for my Cadet to have his/her medication sent on an off campus event. This medication will be sent with the coach, athletic trainer, teacher, chaperone,

counselor, or his/her designee. I hereby request that the medication prescribed for my son/daughter be administered to him/her. I waive and release VFMA&C, its

employees, management, and sponsors from any liability or responsibility for any injuries, illnesses, or damages with this request.

I understand that a completed physical exam must be done on my son/daughter no earlier than June 1

for the incoming school year and before arrival on campus or he/she

will not be able to fully participate in sports or any physical activity until the exam has been completed. All school physical exams must be completed on Health Center

Registration forms. A PIAA, ROTC, and DODMERB forms are not acceptable. I also understand that if any component of the mandatory physical exam is missing it will be

completed by the VFMA&C Health Center staff at my expense.

I further understand that if any information on this form is false, misleading, or omitted which in the opinion of the school would have reflected adversely on the decision for

acceptance, the school, at its discretion, may dismiss my Cadet. I have read and fully understand the health information as submitted by Valley Forge Military Academy

and College.

___________________________________

________________________________

PARENT OR GUARDIAN’S SIGNATURE

CADET SIGNATURE (if age 18 or older)

__________________________________________

______________________________________

DATE