Emerging Scholars Program

Clarion University of Pennsylvania

Health History and Authorization Form

Emerging Scholars: Summer 2008 Program Dates: July 13^th-19^th (Phase I)

July 13^th – 26^th (Phase II)

Student Information:

Name:_____________________________ Date of Birth_________ Female___ Male_____

HomeAddress:_______________________________________________________

___________________________________________________________________

Health History:

Does the student need accommodations?

If yes, please advise so that the University may inform student of the appropriate procedures. _______________________________________________________

__________________________________________________________________

Does the student have allergies, (dietary or other)?___List:____________________________________

Parent/Legal Guardian Information:

Name:____________________________________________________________________

Address:_________________________________________________________________

___________________________________________________________________

Day phone:_______________________________ Night phone:_____________________

Emergency contact name:___________________________________________________

Address:__________________________________________________________________

Day phone:______________________________ Night phone:______________________

___________________________________________________________________

Family Physician:______________________________________Phone:______________

Medical Insurance:__________________________________________________________

Policy Numnbers:____________________________________________________________

Insurance Address:_____________________________________Phone:______________

AUTHORIZATION FOR MEDICAL CARE:

I hereby consent to any and all diagnostic procedures, examinations, care and treatment as deemed necessary by Clarion University’s staff for my child_____________________________________________________________________.

I further consent to authorize the University staff to refer my child for consultation to any licensed medical specialist or to the Clarion Hospital’s Emergency Room as judged necessary, and give authority and power to any such physician or surgeon to render any and all such diagnostic procedures, examinations, care or treatment that she/he may deem necessary or advisable.

I authorize the Emerging Scholars Director or staff member to accompany the student, as circumstances warrant, and authorize him/her to sign the proper permit forms required by Clarion Hospital.

I understand, in case of serious accident or illness involving my child while he/she is in residence at Clarion University, every effort will be made to contact me. A situation may arise when emergency treatment may be necessary and I cannot be reached. In such situations, I hereby authorize Clarion University personnel to make provisions for treatment with the appropriate medical personnel or facility.

I understand that I will be responsible for any casts of care not provided by the University Health Service.

I understand and agree that Clarion University and its University Health Service physicians will not accept responsibility for the following:

1.) medication or treatment not prescribed by Clarion University Health Services physicians and action results from its use; and

2.) actions of the student contrary to medical advice.

_________________________________________ ___________________

Signature of parent/legal guardian Date