Medical Authorization Form

2019 Summer Immersion Program Health Information Form

Student First Name

Student Middle Name

Student Last Name

Student Preferred Name

Student Date of Birth

Gender

Female

Male

Student Cell Phone Number

Relationship Type

Father

Mother

Legal Guardian

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number

Parent/Guardian Permanent Address

Country

Street

City

Region

Postal Code

Emergency Contact Information

If we are unable to reach the parent/guardians listed above, please contact the following people in case of an emergency:

Emergency Contact 1:

Name

Cell Phone Number

Home Phone Number

Relationship

Emergency Contact 2:

Name

Cell Phone Number

Home Phone Number

Relationship

Medical Information

Please indicate any special needs or medical conditions.

Please indicate any allergies to medication, food, insect bites, etc.

Does the student carry an Epi-pen?

Yes

No

Please indicate any medications that the student is currently taking.

Please indicate any respiratory problems and/or if the student has asthma.

Please indicate any physical disabilities.

Please indicate any mental/psychological/emotional health concerns.

Please indicate any vision/hearing impairments.

Please indicate any other special medical concerns and/or pertinent information including recent surgeries, hospitalizations, etc.

* The indication of dietary restrictions and/or allergies on this form is very important as we will use the information provided for meal planning purposes.

Other dietary restriction(s), if applicable:

I currently have health insurance.

Yes

No

I, the student and parents of the student, accept financial responsibility for all health related costs incurred while enrolled in the Wake Forest Summer Immersion Program.

Student First and Last Name

Parent/Guardian First and Last Name

*Health Insurance Information Required.

Insurance Company

Address of Insurance Company

Country

Street

City

Region

Postal Code

Subscriber's Name

Subscriber's ID Number

Group Number

Insurance Company Phone Number

Hospital/Clinic Preference

Physician's Name

Physician's Phone Number

Please upload a copy of both sides of your health insurance card.

Release and Assumption of Risk Agreement*

Important Information - Please read and complete:
Authorization and Consent: Please read and sign below. If the student is under the age of 18, a parent or guardian must also sign. I agree that the attending physician or whomever he or she may designate may evaluate and treat all injuries or illnesses for which help is sought. In the case of a minor student, (under the age of 18) this treatment may proceed without prior notification of the undersigned parent or guardian. I also agree that needed immunizations may be administered. I further agree that the Student Health Service may release any medical information to other health care providers who are involved in my care.

Payment:
Student Health Services expects payment at the time of visit. The individual receiving treatment will incur the cost of the visit, not Wake Forest University or the Pre-College Programs Department.

By typing my signature below, I agree that I have read and provided accurate information above.

Date

Parent / Guardian First and Last Name

Student First and Last Name

Pre-College Programs

Medical Authorization Form

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Medical Authorization Form

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