Medical Information and Authorization Form
Medical Information and Authorization Form
Purdue University’s GERI Summer Residential Programs
This form should be completed by a parent or guardian.
Student Information (All authorizations apply to the below-named student.)
|Name: |
|Program: Comet I Comet II Star I Star II Pulsar I Pulsar II |
|Home Address (Street, City, State, Zip): |
|Home Phone: |Date of Birth: |
|Student’s Physician: |Physician’s Phone: |
Parent or Legal Guardian Information
|Name: |
|Home Address (Street, City, State, Zip): |
|Place of Employment and Address: |
|Home/Evening Phone: |Work/Day Phone: |
|Health Insurance Provider: |Policy Number: |
|Address of Insurance Provider: |
If Parent/Guardian is not available in emergency, please contact:
|Name: |Daytime Phone: |
|Relationship: |Evening Phone: |
Medical Authorization for Treatment of a Minor (Persons under 18 years)
I request and authorize the Purdue University Student Health Center, St. Elizabeth East Emergency Care Center and St. Elizabeth Hospital, medical personnel, agents and employees to provide all reasonably necessary medical care including but not limited to medical transport, hospital tests such as pathology, radiology, anesthesia, surgery and prescription drugs advisable for the health of my child. I acknowledge that no representations, warranties or guarantees as to results or cures will be made. I have also provided complete and true medical history information as requested on the back of this form.
__________________________________ ____________________________ ____________________
Signature of Parent/Guardian Relationship Date
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