Personal Medical Record Form - Summer Practicum printable pdf download

Auburn University

School of Forestry and Wildlife Sciences

Personal Medical Record Form

Summer Practicum

Please Print All Entries

Name_____________________________________________________________________________ Student ID # _____ ____________

Last

First

Middle

Auburn Address __________________________________________________________ City______________ State________ Zip__________

Home Phone: ________________________ Cell Phone: _________________________ E-Mail: ___________________________________

Permanent Address________________________________________________________ City______________ State________ Zip__________

Home Phone: ________________________ Cell Phone: _________________________ E-Mail: ___________________________________

IN CASE OF EMERGENCY, CONTACT:

________________________________________________________________________

Relationship ___________________________________ Telephone Number __________________________

Address___________________________________ City_______________________ State_____ Zip________

___________________________________________________________________

Relationship _______________________________ Telephone Number _____________________________

Address___________________________________ City_______________________ State_____ Zip________

In space provided below, please make us aware of any medical conditions that may need to be taken into account

during an extended experience like Practicum. For example, it would be helpful for us to know if you are prone to severe

reaction to insect bites or stings, asthma, pollen or medicinal drugs, or may be subject to seizure disorders, diabetes side-

effects, heart conditions, or other conditions that may require prompt, specialized attention. We need to be prepared to

provide this information to medical personnel in case you are incapacitated and unable to provide it personally. The health

care providers asked to review this form have suggested that students having life-threatening allergies or conditions also

wear a Medic Alert bracelet. This assures that medical personnel are readily made aware of vital information. Please also

list any food allergies!

If you develop a non-disabling medical problem or injury between the time you submit this form and the

beginning of Practicum, please inform the Practicum Director promptly so appropriate attention can be afforded

you.

Personal Medical Record Form - Summer Practicum