Language
English (US)
Spanish (Latin America)
Summer 2021 Upward Bound @ ASU
Role this Summer
*
Office Staff
Dorm Staff
Instructional Staff
Student
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
ASU Email
example@example.com
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Medical Release for Summer 2021
Are you currently taking any medication?
*
Yes
No
Do you have any medication allergies?
*
Yes
No
Not Sure
Physician's Name
*
First Name
Last Name
Physician's Phone Number
*
-
Area Code
Phone Number
Health Insurance
Comapny Name
Policy Number
Group Number
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TO ANY DOCTOR OR HOSPITAL
I hereby authorize the release of my child’s pertinent medical information to the appropriate professional staff. I give permission to the physician or hospital to secure treatment for him/her and to order medications, injections, anesthesia, or surgery for my child, as named above, in case of emergency. The signature below constitutes authorization to perform any necessary treatment for my child during this field trip.
Allergies or Conditions requiring special consideration:
*
None
Epipen Use
Inhaler
Other
Parent's Full Name
*
First Name
Last Name
Parent's Phone Number
*
-
Area Code
Phone Number
Parent Signature
*
Date
*
-
Month
-
Day
Year
Date
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Covid-19 Documentation
Please upload the documentation you would like to show in place of taking a Covid-19 test every Sunday.
Vaccination Card Upload
Browse Files
Vaccination cards are valid 2 weeks after the last dose.
Cancel
of
Covid-19 Positive Test/Release
Browse Files
The release or test must demonstrate a date that does not expire before June 30, 2021.
Cancel
of
Submit
Should be Empty: