Delaware County Community College
901 South Media Line Road
Media, Pennsylvania 19063, USA
PERMISSION FOR MEDICAL CARE AND RELEASE OF LIABILITY
FOR INTERNATIONAL APPLICANTS UNDER 18 YEARS OF AGE
We, the parents/legal guardians of the applicant, who have the legal right to make decisions on health
care, do h
ereby release Delaware County Community College (DCCC) and the host family from any
liability and grant the following permissions:
In the event of injury or sickness of our son/daughter/ward, we authorize the host parent(s), or
designated
official at DCCC, to select and authorize an appropriate medical provider to provide
medical care and surgical procedures.
We authorize the release of any personal health information of our son/daughter/ward
obtained
in the course of treatment by medical providers to the host parent(s) and/or
designated official at DCCC including health information as defined and described in the Health
Insurance Portability and Accountability Act of 1996, as amended (HIPAA).
In the case of elective surgery, we request that we be notified and our permission obtained
before arrangements are made.
We consent to any medical or surgical treatment by an appropriate medical provider that might
be required by
our son/daughter/ward for any life-threatening, emergency situation. WE DO
REQUEST THAT WE BE NOTIFIED AS SOON AS POSSIBLE, BUT EMERGENCY TREATMENT NEED
NOT BE DELAYED TO PROVIDE SUCH NOTICE.
We agree to assume all financial obligations beyond those covered by insurance for any medical
treatment rendered to our son/daughter/ward while studying at DCCC.
We agree to save and hold harmless DCCC, its employees, and Coll
ege host family for any intervention
in any medical situation regardless of outcome.
Applicant (Print Name) Signature Date
Mother/Legal Guardian (Print Name Signature Date
Father/Legal Guardian (Print Name) Signature Date
This form must be notarized and/or sealed by legal official in home country
__________________________________________ _______________________________________
__________________________________________ _______________________________________
__________________________________________ _______________________________________
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