New friends and memories to last a lifetime are just part of what your child will experience on the Bloomington campus of Indiana University.
Whether or not this is your son's or daughter's first time away from home, we know you still worry. What happens if he or she gets sick or injured and you can't be reached right away?
At Indiana University, we share your concern. That's why we ask that you fill out this form and return it as soon as possible to your School's Science Olympiad Coach, so he or she can send in all student forms together. If he or she gets sick or injured, this form provides vital medical information. It does not mean that every effort won't be made to contact you first, but it does mean that your child can still be treated quickly even if you can not be reached.
Remember ... this form will probably never be used. Safety is our number one priority at IU, especially where children are concerned. But peace of mind is worth the few minutes it takes to complete this form.
I,_____________________________ , being the parent or
legal guardian of ____________________________ , grant the following authorization for medical and/or surgical treatment of this minor by a health care professional should the need arise while he/she is attending the 2006 National Science Olympiad Tournament held at Indiana University Bloomington, for the time period starting MAY 17 and ending MAY 20, 2006.
Please complete ONE of the following:
1) I grant permission to the directors, assistants, or other persons responsible for his/her care to act on my behalf for said minor in granting permission for evaluation and treatment of medical or psychological problems. I understand that should a major medical or psychological problem arise, reasonable attempts will be made to notify me by telephone. In the event that I cannot be reached, I give my consent to such medical treatment as deemed necessary, including surgery, x-ray examinations, and anesthesia to be rendered to said minor by a licensed physician or nurse.
DATE:___________ SIGNATURE:______________________________
2) I do not wish medical care of any kind, except in case of an emergency.
DATE:___________ SIGNATURE:______________________________
3) I authorize limited medical care as follows: ____________________________________________________
DATE:___________ SIGNATURE:______________________________
Participant's name:_______________________________________
| Social Security Number:______-___-_______ Age:________ | Birthdate:__/__/__ Date of last Tetanus Toxoid: __/__/__ |
Past health/injuries: _____________________________________________________________________________________
| Present health:______________________________________ | Allergic reactions: ____________________________________ |
| Present Medication: __________________________________ |
Other information that would be useful in the event medical treatment is necessary: ______________________________________________________________ |
In an emergency, parents or legal guardians can be reach as follows:
Name:_______________________________________________
Relationship to minor: ________________________________
Address: ____________________________________________
City, State, Zip:______________________________________
Daytime phone: (___)___-____ Evening phone: (___)__-____
Name:_______________________________________________
Relationship to minor: ________________________________
Address: ____________________________________________
City, State, Zip:______________________________________
Daytime phone: (___)___-____ Evening phone: (___)__-____
Name:_______________________________________________
Relationship to minor: ________________________________
Address: ____________________________________________
City, State, Zip:______________________________________
Daytime phone: (___)___-____ Evening phone: (___)__-____
If other information would be helpful in contacting you, please indicate below: __________________________________________________________________________________
Parents or legal guardians are responsible for the cost of a minor's medical treatment. When available, insurance information will be processed by the health facility performing the treatment, otherwise you will be contacted for payment by cash, check, or credit card.
Insurance Company:___________________________________
| Address: ____________________________________________ | City, State, Zip: _____________________________________ |
| Policyholder's name:__________________________________ | Policy Number: ______________________________________ |