Medical Authorization / Release Form printable pdf download

Medical Authorization / Release Form

A. Release Form

I, ____________________________ (parent or legal guardian’s name), as parent or legal guardian of ____________________

(child’s name) in consideration of Recreational Services of the University of Iowa granting the child permission to participate in the UI

School of the Wild hereby assume all risk of personal injury (including death) which may result from any UI School of the Wild activity

including transportation-related accidents; and acting for the child, myself, our heirs, personal representatives and assigns do hereby

release the University of Iowa, its Board of Regents, individually and collectively, Recreational Services, members of the University

faculty, administrative officers, all other agents, representatives and employees of the said university, all instructors and all participants

of said UI School of the Wild program from all liability, including claims and suits at law or in equity, for injury fatal or otherwise, which

may result from the child taking part in UI School of the Wild activities, unless such injury is a direct result of the negligence of the

University of Iowa or that of its employees.

______________________________________

Medical Authorization Form

Signature

THIS TREATMENT AUTHORIZATION MUST BE SIGNED BY A PARENT OR GUARDIAN, IN ORDER FOR STUDENT

TO PARTICIPATE IN UI SCHOOL OF THE WILD.

Medical and Surgical Authorization

I hereby authorize and give my consent to the health authorities of the University of Iowa or any licensed physician to perform upon or

administer to _____________________ (student’s name) any reasonably necessary surgical or medical treatment.

I also give

permission to administer whatever anesthetic may be necessary or advisable during the medical or surgical procedures.

This

authorization is intended to cover emergency treatment, immunizations, injections, and minor operations and procedures.

I agree to assume all costs related to such treatment. I authorize my insurance company to pay benefits to University Hospitals or

Mercy Hospital. Also, I authorize the disclosure of medical information to my insurance company for the purpose of claim.

This authorization will be in effect while the student is attending any session of the UI School of the Wild.

I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR ANY MEDICAL OR OTHER CHARGES IN CONNECTION

WITH STUDENT’S ATTENDANCE AT THIS SCHOOL. (EACH STUDENT MUST PROVIDE HIS/HER OWN MEDICAL

INSURANCE).

Date ____________________________________________

Name _____________________________________

Parent/Guardian - Please Print

Relation to Student ________________________________

Signature __________________________________

Address _________________________________________

Home Phone _______________________________

Insurance Company _______________________________

Work Phone ________________________________

Insurance Co. Address _____________________________

Policy Holder _______________________________

________________________________________________

Hospital ___________________________________

________________________________________________

Doctor ____________________________________

PLEASE LIST ANY MEDICATIONS BEING TAKEN, ALLERGIES OR MEDICAL PROBLEMS THAT THE STUDENT

MIGHT HAVE WHICH MEDICAL AUTHORITIES SHOULD BE AWARE OF___________________________________

________________________________________________________________________________________________

Elementary or secondary school student is attending ______________________________________________________

The University of Iowa requests this information for the purpose of registration in Recreational Services programs. No persons outside the

University are routinely provided this information except for items of directory information such as name and local address. Responses to

all items are required. If you fail to provide the required information, the University may not consider your registration. medformsow/2013

Medical Authorization / Release Form

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