Dd Form 2492 Dod Medical Examination Review Board (Dodmerb) Report Of Medical History (Page 4 of 4) in pdf

Dd Form 2492 Dod Medical Examination Review Board (Dodmerb) Report Of Medical History Page 4

FORM IV

MEDICAL CARE AUTHORIZATION

We are providing this form in an effort to provide the best quality medical care in the event a new cadet becomes

sick or injured. We intend to involve the parents or legal guardians in any significant medical treatment but medical

care may be required when a parent or guardian is not available.

Please include with this form a copy (front and back) of the health insurance card or HMO card that your son/

daughter is covered under. This is a precaution in an attempt to prevent unnecessary medical expenses in the

event that your son/daughter needs to seek medical treatment.

I hereby grant permission for my son/daughter to receive medical attention while participating in the New Cadet

Training Program and related activities should the need arise. This includes medical attention in cases of emer-

gencies.

New Cadet Name: ___________________________________________________

New Cadet Signature: ________________________________________________

Student ID Number: _________________________________________________

Parent or Guardian Name: ____________________________________________

Parent or Guardian Signature: _________________________________________

Date: _________________________________

Dd Form 2492 Dod Medical Examination Review Board (Dodmerb) Report Of Medical History Page 4