Overnight Visit / Prospective Student Medical Consent Form (Page 2 of 2) in pdf

Health Problems/Concerns: (Please list any serious or chronic medical conditions; or recent illness/surgery. Please give

dates.)

Insurance Information: (We recommend that the student carry an insurance card or copy of one with them.)

Name of Company and Address__________________________________________________________________

Company Phone Number: ______________________________________________________________________

Name of the policy holder________________________________________________________________________

Permission, Medical Authorization, and Release Statement

The health history is correct so far as I know and I acknowledge that it is important for the provision of proper medical care

(if deemed necessary) during a campus visit. I fully understand the dangers, hazards, and risks inherent in the Valparaiso

University Overnight Visit. I further acknowledge that the University will not administer regularly prescribed medication.

Should the University be unable to reach parent/guardian or the emergency contact person immediately to inform them of

an emergency medical issue, I authorize the University or medical agency to initiate treatment in these circumstances. I

understand and agree that Valparaiso University assumes no responsibility for any injury or damage that might arise out

of or in connection with such authorized emergency medical treatment.

I hereby release The Lutheran University Association, Inc., d/b/a Valparaiso University from all actions, damages, claims

or demands which I, my heirs, executors, and administrators, or assigns may have against Valparaiso University, its

successors, or assigns for all injuries caused by, related to, or arising out of my voluntary participation in the Valparaiso

University Overnight Visit Program

I also understand that Indiana State Law and Valparaiso University policy prohibits those who are under 21 years of age

from buying or consuming alcoholic beverages, and that the illegal use, possession, distribution, or sale of any illegal

drugs is prohibited by state and federal law, in addition to Valparaiso University policy. Any violation of these policies may

result in disciplinary action, and/or possible arrest.

Signature of Prospective Visitor____________________________________

Date________________

If the Prospective Student Visitor is a minor and under the age of 18:

I, the undersigned parent or guardian, do hereby grant my permission for my daughter/son to visit Valparaiso University

for participation in the Valparaiso Overnight Visit program. In the event of an injury or illness during this visit, medical care

may be sought for my child; as the urgency or emergency warrants. I understand that the university will attempt to contact

me regarding my child’s condition, however medical care will not be delayed if I cannot be reached. I hereby release

Valparaiso University and their agents, employees, and representatives from any and all claims and liability arising in any

way out of its exercise of this authority. I understand and agree that all bills for medical care and treatment will be

forwarded to my insurance company or me, and that it will be my responsibility to see that such bills are paid.

I hereby release The Lutheran University Association, Inc., d/b/a Valparaiso University from all actions, damages, claims

or demands which I, my heirs, executors, and administrators, or assigns may have against Valparaiso University, its

successors, or assigns for all injuries caused by, related to, or arising out of my child’s voluntary participation in the

Valparaiso University Overnight Visit Program

Signature of Parent/Guardian ______________________________________ Date_________________

Parent/Guardian Name (Please Print)_________________________________

Please fill out this form completely.

Overnight Visit / Prospective Student Medical Consent Form Page 2