Sinclair Community College-UB 2-Medical Form

THIS FORM MUST BE COMPLETED IN ITS ENTIRETY.

Purpose: This form enables parents (or a participant age 18 or over) to authorize emergency medical treatment in the event of illness or injury while the child is a participant in any activity or trip with Sinclair Community College and provides health information and medical insurance information about the child.

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Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Insurance Information:

If yes, complete below:

In the event that reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of medical treatment deemed necessary by licensed paramedics, physicians, or dentists and to have my child transported to the closest medical emergency facility accessible. This authorization DOES NOT COVER major surgery unless the medical opinions of two (s) physicians or dentists concurring on the necessity of life-saving surgery are obtained BEFORE the surgery is performed.

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If participant is age 18 or over, they must also sign below.

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Medical Information & Consent Form