Orlando Project Parental Consent and Authorization Form
Name of Student
First Name
Last Name
What school does your son or daughter attend?
USI
IUI / PUI
Purdue
Other
The undersigned do hereby authorize Luke Holladay or such substitute as he may designate as agent for the undersigned to consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment as hospital care for the above student which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon, licensed under the general or special supervision of any physician and surgeon, licensed under the Provision of Medicine Practice Act or of any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital or elsewhere.
This authorization, consent, and waiver of liability will remain effective, unless revoked in writing by the undersigned, and delivered to the aforesaid agent.
Parent or Guardian Name
First Name
Last Name
Parent or Guardian Email
example@example.com
Parent or Guardian Name
Please enter a valid phone number.
Medical Insurance Company
Medical Insurance Policy Number
Please describe any special medication and/or medical information that would be necessary or helpful.
Signature
Submit
Should be Empty: