University Of Central Florida-EDGE-UB-YPP Packet

UNIVERSITY OF CENTRAL FLORIDA Youth Protection Program Medical Information and Authorization for Medical Care
Program/Activity Name TRIO Upward Bound Program - Project EDGE
Today's Date

MonthDayYear
Date
- Child's Name*
  
  First NameLast Name
- Email*
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number:
  (999)999-9999
- Alternate Phone Number:
  (999)999-9999
- Date Of Birth
  
  MonthDayYear
  Date
- Height
- Weight
- Person to contact in case of emergency
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number:
  (999)999-9999
- Alternate Phone Number:
  (999)999-9999
- Family Physician:
- Phone Number:
  (999)999-9999
- Insurance Provider:
- Phone Number:
  (999)999-9999
- Insurance subscriber name:
- Group Number:
- Policy Number
- (Note: UCF does not offer any form of health, liability, or other types of insurance for participants. Please attach a copy of the front and back of your insurance card with this form.
- Alternate person to contact:
- Relationship
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number:
  (999)999-9999
- Alternate Phone Number:
  (999)999-9999
- Please list any current medical concerns or medical history we need to know about your child: (Ex .past injuries, current conditions, physical limitations, etc.)
- List any allergies your child has: (Ex. medications, stings, food, iodine, latex, etc.
- Lists any medication your child. is currently taking, the purpose, dosage, and times taken.
- Does your child need any accommodations to safely participate in the program/activity? If yes, please explain:
- Does your child require any assistance with his or her medications? If so, please explain:
- Authorization for Medical Care
  I understand that my child is voluntarily participating in a University of Central Florida
  Program/Activity. By signing this form I hereby acknowledge that all information is accurate and current, that any activity restrictions, allergies, and medications are listed on this form, and to the best of my knowledge, my child is capable of participating safely in the Program/Activity. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this Program/Activity. I agree to notify the Program/Activity of any changes in my child's mental, physical, or medical condition before the Program/ Activity begins.
  I understand that the University of Central Florida does NOT provide medical insurance for my child and that I am responsible for providing my own insurance. I should consult my child's physician before allowing my child to participate in this Program/Activity. In the case of accident or illness, I hereby authorize the Program/Activity staff to administer or seek medical treatment for my child, as they see fit, including routine first aid care or emergency medical treatment. I hereby agree to indemnify and hold harmless the Program/Activity, the University of Central Florida, the University of Central Florida Board of Trustees, the State of Florida and Florida Board of Governors and their respective employees, agents, officers, volunteers and servants from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment or other actions by UCF and its employees, agents, officers, volunteers and servants relating thereto. Iacknowledge that I am solely responsible for any hospital, physician or other costs arising out of any bodily injury or property damage sustained by my child or through my child's participation in such voluntary Program/Activity.
- Name of Participant
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- Signature of Parent or Gaurdian
  
  Clear
- Parent or Guardian Name:
  
  First NameLast Name
- TRIO Upward Bound Program - Project EDGE
- Child's Name
- DOB
  
  MonthDayYear
  Date
- Parent/Guardian Names
- Home Phone:
  (999)999-9999
- Cell Phone:
  (999)999-9999
- Work Phone:
  (999)999-9999
- Alternate Number:
  (999)999-9999
- Please select the appropriate authorization below: I. Authorized Pick Up Please list any individual who is authorized to pick up your child, including yourself. Each authorized person must be at least 16 years of age. The above-name child will not be permitted to leave the program/activity with anyone who is not listed below. Authorized individuals must pick up the child in person and may be requested to show identification to program/activity staff. Children will not be released to persons who fail to provide acceptable identification upon request.
  
  I authorize the following responsible persons to pick up my child from the program/activity.
- Authorized Person
- Phone Number
- Relationship to Child
- Please note that children must be picked up by the designated times. If none of the authorized persons listed above are able to be reached, program/activity members will contact the local police department as a last resort to take your child home.
- II. Unauthorized Pick Up - Please specify any individuals who are not authorized to pickup your child.
- Relationship to Child
- My child is at least 16 years of age and will be responsible for her/his own transportation to and from the program. My child may sign herself/himself out at the end of the program/activity.
- Signature of Parent/Gaurdian
  
  Clear
- Print Parent/Guardian Name*:
- Date
  
  MonthDayYear
  Date
- *Please note that only the enrolling parent/guardian will be permitted to complete this form.
- I, the parent and/or legal guardian of the Participant, hereby give the University of Central Florida, and the University of Central Florida Board of Trustees, the right and permission to use, reproduce, edit, exhibit, project, display, record, copyright and/or publish my/my child's images, likeness, and voice in the whole or in part, on any materials developed during participation in the Program/Activity and thereafter, and to circulate the same in all forms and media for any lawful purpose whatsoever. My consent includes, but is not limited to, images, likenesses, and recordings that may be deemed to be educational records under the Family Educational Rights and Privacy Act of 197 4 ("FERPA").I understand and agree that my/my child's image will become part of the University of Central Florida's photograph file and that it may be distributed to other organizations or individuals for use in any publications, media, or technology now known of or hereafter developed in the future for any lawful purpose whatsoever without further permission from me. I also understand that I will receive no compensation in connection with the use of my/my child's image. I hereby waive the right to inspect or approve my/my child's image or any finished materials that incorporates the image. I further release, discharge, and agree to indemnify and hold harmless the University of Central Florida, and the University of Central Florida Board of Trustees, the State of Florida and the Florida Board of Governors and their respective employees, officers, agents, volunteers, licensees, successors, legal representatives and assignees ("Releasees") from any liability for violation of any personal or proprietary right that I may have in conjunction with said pictures or images and with the use thereof. I further acknowledge and agree that the Releasees shall not be responsible for any use of such image, likeness or recording by any third party accessing it through the internet or any other means
  
  YesNo, I do not grant permission for my /my child's image, likeness or recording to be used in any form.
- Print Parent/Guardian Name:
- Parent/Guardian Signature:
  
  Clear
- Date
  
  MonthDayYear
  Date
Should be Empty:

UNIVERSITY OF CENTRAL FLORIDA Youth Protection Program Medical Information and Authorization for Medical Care