Hofstra In La - January 2015 Application - Complete All Three Parts (Page 4 of 4) in pdf

Hofstra in LA

January 2015 Application

Complete All Three Parts

Part III – Emergency Medical Care Authorization

On occasion a student participating in a University-sponsored travel program may face a health

emergency requiring local hospitalization and emergency treatment. For such an emergency Hofstra

University requires that the student and his/her parent or guardian sign the following statement and that

the student carry it on his/her person at all times during the trip.

Name:___________________________

Hofstra ID #:___________________

Sex: □ F

□ M

Date of Birth:__________________

Current Address:_______________________________________________________

_____________________________________________________________________

Telephone Number:_____________________________________________________

Student’s Blood Type:___________________________________________________

Known Allergies to Medication:___________________________________________

Known Food Allergies: __________________________________________________

Emergency Contact Information

In the event of an emergency, Hofstra University may notify the following emergency contacts:

Emergency Contact 1

Name: ______________________________________________

Relationship: _________________________________________

Address: ____________________________________________

Phone: ______________________________________________

Emergency Contact 2

Name: ______________________________________________

Relationship: _________________________________________

Address: ____________________________________________

Phone: ______________________________________________

To prevent delay in the event of an emergency requiring hospitalization and/or surgery, I hereby authorize

the appropriate authority of the Hofstra University program to secure whatever treatment is deemed

necessary for me/my child including the administration of an anesthetic and/or surgery.

_____________________________________________________

_________________________

Student’s Signature (or if under 21 Parent/Guardian Signature)

Date

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