Parental Consent/ Medical & Emergency Contact Form - Minors Unpaid printable pdf download

PARENTAL CONSENT/ MEDICAL & EMERGENCY CONTACT FORM – MINORS UNPAID

Student Name: ______________________________________________________________

Last

First

Middle

Home address: ________________________________________________________________

Student Cell Phone (if applicable): ____________________Birth date: ____________________

Parent #1 or Legal Guardian: ________________________________________________________

Last Name

First

Middle

Telephone Contact Information (Parent #1/Guardian): Day: ____________; Evening: __________ Cell:

___________

Parent #2:

_______________________________________________________________________

Last Name

First

Middle

Telephone Contact Information (Parent #2):

Day: ____________; Evening: __________ Cell: ___________

_____________________________________________________________________________

Chronic medical conditions requiring ongoing care:

Allergies (Animals, latex, food, meds, other): _________________________________________

Prescription medicines used regularly or needed on occasion: __________________________

Date of last tetanus booster: __________________________

Any other health issues of Student of which MIT should be aware? _________________________

Student’s Primary Care Physician (Name/Phone): ____________________________________

Health Insurance: ___________________________________________ __________________

Name of Insurance Co. and Primary Subscriber

Policy Number

I am not aware of any medical condition(s) which would interfere with my child’s participation in this program and I

grant permission for my child to participate in (Insert program/DLC internship name) __________________

_______________________________(the “Program”, as further described in the attached release and/or Hazards

Assessment), for the following date(s) or period of time: __________________________.

Additionally, in case of emergency and I/we cannot be reached, I, the undersigned parent/legal guardian of the

above-named child, do hereby authorize the MIT program representatives to seek medical attention deemed

necessary, by qualified medical personnel, during the entire time that my child is participating in this Program. I/we

understand that I/we will be responsible for any medical charges incurred in the treatment of my child, in the case of

an emergency, that are not covered by my family’s health insurance.

(If applicable, check attachments included or insert “NA”) Both Student and Parent acknowledge that they’ve

reviewed the attached Exhibit A, Summary of Hazards Assessment for Programs Involving Minors _____ and the

MIT Department/Lab/Center/Program Policies and Procedures, ______, which Student agrees to follow.

Release required: Yes X No ___

________________________________________

________________________

Signature of Student

Date

________________________________________

________________________

Signature of Parent or Guardian

Date

Distribution:

Signed original(s), including all attachments, or executed electronic copies – DLC AO or PA or Program Leader

Copy – PI/Supervisor/Program staff (to bring to Medical if minor is injured)

Record retention – 3 years after the end date of the program.

Parental Consent/ Medical & Emergency Contact Form - Minors Unpaid

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