MEDICAL HISTORY/MEDICAL RELEASE FORM

(For your child's safety and welfare, please complete all sections)

School

Student Name

Date of Birth

Date

Student SS#

Parent/Guardian Name

First NameLast Name

Street Address

Parent/Guardian Cell phone number

Please enter a valid phone number.

Home Phone

Message Phone

Parent Email

example@example.com

Physician

Physician Phone

Is your child currently under a physician's care or using medication?

YESNO

Please explain (medications)

Are there any limits on your Childs physical activities?

yesno

Please explain (physical limitations)

Does your child have allergies (medications, insects, food, etc)

yesno

Please explain (allergies)

Does your child have any medical problems we should be aware of, or has your child been seriously ill in the last three years?

yesno

Please explain (serious illness or medical problems)

Is you child covered by medical insurance

yesNo

Company

Policy Number

In case of emergency and we cannot contact you, whom should we call?

NAME of emergency contact person

Relationship to child

PHONE

CELL PHONE

Should my child (named above), participating in the UC Clermont College Upward Bound program, require medical attention and/or care while participating in the UC Clermont College Upward Bound program, I give my consent to medical examinations and necessary emergency treatment including drugs and x-rays, as may be deemed by the attending emergency room physician. Should an emergency arise requiring major surgical procedures and I cannot be contacted, the attending physician has my consent to act as emergency medical judgment may dictate. I understand that I, my heirs, executors, and administration forever release the staff of the Upward Bound program and the University of Cincinnati from all claims, damages, actions or cause of actions that may occur due to any decisions which they make in respect to the emergency medical care/treatment of my child. I also understand that any actions of the UC Clermont College Upward Bound staff will be guided by the best interest of my child.

Date

Signature of Parent/Guardian (This consent will be effective so long as my child is a participant in the UC Clermont College Upward Bound program.)

MEDICAL HISTORY/MEDICAL RELEASE FORM

TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN

MEDICAL RELEASE TO BE SIGNED BY PARENT/GUARDIAN