EXHIBIT B4-C
THE UNIVERSITY OF TEXAS AT DALLAS
MEDICAL INFORMATION AND RELEASE FORM — ADULT
(Please Print Clearly)
Name ____________________________________________________________________________________________________________________________
First
Last
Address___________________________________________________________________________________________________________________________
City ___________________________________________ State ________________ Zip _____________________
Telephone Number (____)____________________ Birthdate _____ / _ ___ / _____
Area Code
Emergency contact persons and phone numbers:
Name _________________________________________________________
Name ________________________________________________________
Relation _______________________________________________________
Relation ______________________________________________________
Telephone Number-day (____) ____________________________________
Telephone Number-day (____) ___________________________________
Telephone Number-night (____) ____________________________________
Telephone Number-night (____) ___________________________________
Medical Information:
Physician Information
Dentist Information
Name _________________________________________________________
Name ________________________________________________________
Address _______________________________________________________
Address ______________________________________________________
Telephone Number-office (____) ___________________________________
Telephone Number-office (____) __________________________________
Telephone-emergency (____) ______________________________________
Telephone-emergency (____) _____________________________________
Allergies _________________________________________________________________________________________________________________________
ealth Insurance Comp
________________________
Telephone (____) __________________
Group # _____________ Policy # _______________
I.D. # ______________________________________________________
Medication(s) you are taking (including dosage) _________________________________________________________________________________________
Date of last Tetanus/Diphtheria Inoculations_______________________________ Blood type
Special Health Needs or Concerns ____________________________________________________________________________________________________
EMERGENCY MEDICAL AUTHORIZATION
I, the undersigned, do hereby authorize The University of Texas at Dallas and its designated representatives to consent, on my behalf, to any medical/hospital care
or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or
treatment rendered pursuant to this authorization.
The effective dates for this authorization are ____________________ through ______________________
I am eighteen years of age or older, have read the above authorization, and confirm that the information contained therein is true and accurate.
_________________________________________________________ Date: __________________________________________________________________
(Signature of Participant)*
Privacy Statement: With few exceptions, you are entitled on your request to be informed about the information U.T. Dallas collects about you. Under
Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under Section 559.004 of the Texas
Government Code, you are entitled to have U.T. Dallas correct information about you that is held by us and that is incorrect.
Original: Custodian
Copy: Faculty or Staff member traveling with the group.
*S
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A
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IGNATURE REQUIRED ON COMPLETED FORM FOR PARTICIPATION IN THE ABOVE
REFERENCED
CTIVITY AND
OR
RAVEL