Fillable Future Problem Solving Program International Conference 2022 Medical

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Future Problem Solving Program International Conference 2022 Medical

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Future Problem Solving Program International Conference 2022
Medical Information/Release
Form
Participant Information
Last Name
First Name
Street Address
Date of Birth
Male
Female
City, State, Zip
Phone
Event Information
Intern atio na l Confe re n c e; Univ e rs ity of Massachusetts Amherst
June 8-12, 2022
Medical Emergency Contact Information
Person to Contact First:
Back-up Contact (Friend or Relative):
Name
Name
Relation to Participant
Relation to Participant
Daytime Phone
Daytime Phone
Evening Phone
Evening Phone
INSURANCE POLICY INFORMATION
Yes No The above-named participant is covered by health insurance.
(If yes, provide the following information, which is required to expedite treatment and to facilitate the
billing process.)
PH’s Date of Birth
Relation to Participant
Occupation
Employer Address
Insurance Co. Phone
Plan #
PARTICIPANT ALLERGIES AND/OR MEDICATIONS
List any allergies participant has and how the allergy affects the participant.
List any current medications and purpose of medications taken by the participant.
PARENTAL PERMISSION
I give my permission for such diagnostic and therapeutic procedures as may be deemed necessary for my son/daughter by any cooperating
medical facility. I understand that any health care facility will make every reasonable effort to contact me first, time and conditions permitting. I
understand I am responsible for charges incurred. I have read and understand this form and have had an opportunity to ask any questions about it.
Printed Name
Signat ur e
Relatio ns h i p
Date
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Future Problem Solving Program International Conference 2022 Medical

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Completed 17 May 2022

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