Program For Minors Medical Information And Release Form printable pdf download

Program for Minors Medical

Information and Release Form

NAME OF PROGRAM: _____________________________________________________________________________

NAME OF PROGRAM PARTICIPANT: ____________________________________________________________________

ADDRESS: __________________________________________________________________________________________

CITY: _________________________________________________STATE: ___________________ZIP: ________________

DATE OF BIRTH: __________________ SEX: ________________ HEIGHT: ________________ WEIGHT: _____________

PARENT (or guardian) NAME: _________________________________________________________________________

ADDRESS: __________________________________________________________________________________________

CITY: _________________________________________________STATE: __________________ZIP: _________________

CELL PHONE: ( ) _________________________ EMERGENCY PHONE: ( ) _________________________

EMERGENCY CONTACT NAME: __________________________________________ RELATION: ____________________

CELL PHONE: ( ) _________________________ EMERGENCY PHONE: ( ) __________________________

PRIMARY CARE PHYSICIAN: ____________________________________ PHONE: ( ) _________________________

DO YOU HAVE HEALTH INSURANCE? YES: _________ NO: _________

______________________________ _____________________________ ______________________________

NAME OF CARRIER POLICY NUMBER

Name of Primary Insured

A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD MUST BE ATTACHED.

Does the Program Participant have any chronic or acute medical problems? YES: _________ NO: _________

Please explain: ______________________________________________________________________________________

__________________________________________________________________________________________________

List any allergies to food, pollen, or medicine: _____________________________________________________________

List any medications being taken at present time: _________________________________________________________

List any other conditions we should be aware of: __________________________________________________________

My child has permission to attend a Program for Minors sponsored by the University of North Texas. I fully realize that

injury or illness to my child may result from or during participation in the program. In case of injury or illness, I give

permission for my child to be given medical treatment as deemed appropriate. I further give permission for the

information provided on this form to be shared with appropriate medical personnel. I further give permission for and

grant authority to the program representatives to sign on my behalf the Notice of Privacy Practice that patients are

required to receive in accordance with federal law. I understand and acknowledge that I will be responsible for any

medical bills incurred by my child at the University of North Texas Student Health and Wellness Center, at a local

hospital or elsewhere.

Signature: _____________________________________________________ Date: ______________________

RMS‐334

Updated 3/2015

Program For Minors Medical Information And Release Form