Overnight Visit / Prospective Student Medical Consent Form
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2Overnight Visit / Prospective Student Medical Consent Form
Participant’s Name: _______________________
Visit Date: ___________________
We are glad that you are visiting our campus, and we hope that your experience at Valparaiso University is helpful and
enjoyable. Please be sure to call the Admission Office to schedule your overnight visit; this form does not do this for you.
To ensure that your visit is the best it can be, you must adhere and comply with the following rules while on campus:
1.
I will remain on campus and accompanied by my host or hostess
at all times, including in
residence halls or
anywhere else, while participating in the Valparaiso University Overnight Visit.
2.
I may only leave campus if on foot or by riding the V-Line while accompanied by my host or hostess.
3.
I will not attend any off-campus parties or social functions, nor will
I consume any alcohol or illegal
substances in any circumstance while visiting the Valparaiso University campus.
I understand that Valparaiso
University is a dry campus and absolutely no alcohol is permitted on the campus at any time.
4.
I agree to comply with all Valparaiso University policies,
as stated in the Student Guide to University Life, during
my on-campus Valparaiso University Overnight Visit.
5.
I am aware of the Residence Hall Visitation Hours:
Members of the opposite sex may be in rooms from Sunday-Thursday, from 10:00 a.m. until 1:00 a.m.
Health and Contact Information
Please type or print
Participant’s Name: _______________________ Birth Date: ____________ Age: ___ Sex: M___ F___
Home Address: __________________________ City: ____________________State: ____ Zip:_______
Home Phone: (
)_____________________ Cell (
)___________________
Parent/Guardian: ___________________________
Work Address: __________________________ City: ____________________ State: ____ Zip: _______
Work Phone (
)___________________ Cell (
)___________________ Hotel: _____________________
E-mail: _____________________________________
Parent/Guardian: ___________________________
Work Address: __________________________ City: ____________________ State: ____ Zip: _______
Work Phone (
)___________________ Cell (
)___________________ Hotel: _____________________
E-mail: _____________________________________
If neither parent/guardian is available in an emergency notify:
Name: ___________________________
Work Address: __________________________ City: ____________________ State: ____ Zip: _______
Work Phone (
)______________________ Cell (
)___________________
Allergies: (insect stings, medications, hay fever, asthma, other. Please list severity of condition and treatment, (i.e. ice,
prescription, over-the-counter medications).
Dietary Restrictions: (Please list food allergies, reaction to food, and any treatment used; also list any religious or
vegetarian restriction or requirements)
Please fill out this form completely.
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