Exhibit B4-B - Medical Information And Release Form - Minor
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1EXHIBIT B4-B
THE UNIVERSITY OF TEXAS AT DALLAS
MEDICAL INFORMATION AND RELEASE FORM — MINOR
(To be Completed by Parent or Legal Guardian. 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 ___________________________________________________________________________________________________________
Health Insurance Company _______________________ 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 parent or legal guardian of ___________________________________, do hereby authorize The University of Texas at
(name of minor)
Dallas and its designated representatives to consent, on my behalf, to any medical/hospital care or treatment to be rendered to
_________________________________ upon the advice of any licensed physician. I agree to be responsible for all necessary
(name of minor)
charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
The effective dates for this authorization are ____________________ through _____________________.
By signing this authorization, I represent to The University of Texas at Dallas that I have legal authority to provide consent for this
minor child.
_________________________________________________________ Date: ____________________________________________________
(Signature of Parent or Legal Guardian)*
_________________________________________________________
(Printed Name of Parent or Legal Guardian)
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.
Rev. 7/28/2011
*S
-
A
/
T
IGNATURE REQUIRED ON COMPLETED FORM FOR PARTICIPATION IN THE ABOVE
REFERENCED
CTIVITY AND
OR
RAVEL
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