Medical Treatment Authorization Form

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Medical Treatment Authorization Form
Participant’s name _____________________________________________________
DOB ____/_____/_____ (mm/dd/yyyy)
Sport: _______________
Date of Camp _____________
Each participant should have his or her own medical insurance. Participants are
automatically enrolled in KSU’s camp insurance plan. Eligible covered expenses will be
paid only if they are in excess of other valid and collectible insurance
1. List any medical conditions that camp personnel should be aware of:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. List any medications currently taking:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. List any allergies:
__________________________________________________________________
__________________________________________________________________
Emergency Contact:
Name ____________________________________________________________
Daytime Telephone: _________________________________________________
Nighttime Telephone ________________________________________________
Name of Medical Insurance Company : _________________________________
Telephone: ________________________________________________________
Policy number: _____________________________________________________
I __________________________________________ as the parent or guardian of the
participant named above, authorizes KSU to seek medical and/or surgical treatment
which is reasonably necessary to care for the participant. I further authorize the medical
facility that treats the participant to release all information needed to complete insurance
claims. I acknowledge my responsibility to pay all costs associated with the participant’s
medical care and authorize all insurance payments, if any, to be made directly to the
medical facility.
_________________________________ ________________
Signature (Parent or Guardian)
Date

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