Mysa Parent Consent Samford University printable pdf download

Mysa Parent Consent Samford University

Minority Youth Science Academy 2014

Medical and Personal Information

Student Name:___________________________

Age:_______ Gender:____________________

Date of Birth:____________________________

Cell Phone:_____________________________

Father/Legal Guardian:____________________

Mother/Legal Guardian:___________________

Home Phone:____________________________

Work Phone:____________________________

Cell Phone:______________________________

Email:__________________________________

Physician’s Name:________________________

Physician’s Phone:________________________

Name of Insured:_________________________

Insurance Carrier:________________________

Policy Number:__________________________

Group Number:__________________________

Known Allergies:_______________________________________________________________________

_____________________________________________________________________________________

Medications taken regularly:______________________________________________________________

_____________________________________________________________________________________

In case of emergency, contact:____________________________________________________________

Phone:_________________________________

Relationship:____________________________

Relative or friend to notify in case of an emergency and we cannot locate the emergency contact:

Name:_________________________________

Phone:_________________________________

Any additional information about the student’s health/health history that we should be aware of:

_____________________________________________________________________________________

Mysa Parent Consent Samford University