Adirondack Community College-UB 2-Medical Authorization

2025-2026 MEDICAL AUTHORIZATION FORM
TRIO Upward Bound at SUNY Adirondack
640 Bay Road | Queensbury, NY 12804
Phone: 518-743-2299 | Email: upwardbound@sunyacc.edu

Student Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
mm-dd-yyyy
Sex
Social Security Number
999-99-9999
Age
Cell Phone #
(999)999-9999
Home Phone #
(999)999-9999
Work Phone #
(999)999-9999

Parent/Guardian 1

First NameLast Name
Relationship to Student
Cell Phone #
(999)999-9999
Work Phone #
(999)999-9999
Alternative Phone #
(999)999-9999
Parent/Guardian 2

First NameLast Name
Relationship to Student
Cell Phone #
(999)999-9999
Work Phone #
(999)999-9999
Alternative Phone #
(999)999-9999
If not available during an emergency, please notify:
Emergency Contact

First NameLast Name
Relationship to Student
Cell Phone #
(999)999-9999
Work Phone #
(999)999-9999
Alternative Phone #
(999)999-9999
Insurance Carrier
Policy Number

In the event of an emergency, when efforts to contact parent/guardian and emergency contact have been unsuccessful, I hereby give consent for the following medical care providers and local hospital/s to be contacted:

Rows	Name	Phone #
Primary Care Physician
Dentist
Hospital

Operations or Serious Injuries:
Medical Conditions:
Psychological or Emotional Conditions:
Allergies:
Special Diet:
Activity Restrictions:
Medication (Name) and dosing schedule:
MEDICAL AUTHORIZATION RELEASE

The above named child has permission to engage in all prescribed TRIO Upward Bound at SUNY Adirondack activities, except those noted above. I certify that I am the legal parent and/or have the legal ability to sign this authorization form on behalf
of the above named child. In the event of illness or accident, I hereby authorize and consent to the administration of all medical/and or surgical treatment(s) to my child by a licensed physician or hospital in the event I am not able to consult with the attending physician(s), attempts to contact me have been unsuccessful, and the attending physician(s) deem it advisable to proceed with such treatment(s).
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature
Date

MonthDayYear
mm-dd-yyyy