Fillable MEDICAL INFORMATION AND RELEASE FORM Students Name Date (Alabama State University)

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MEDICAL INFORMATION AND RELEASE FORM Students Name Date (Alabama State University)

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The MEDICAL INFORMATION AND RELEASE FORM Students Name Date (Alabama State University) form is 2 pages long and contains:

  • 2 signatures
  • 11 check-boxes
  • 39 other fields

Country of origin: US
File type: PDF

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Page 1 of 2
MEDICAL INFORMATION AND RELEASE FORM
Student’s Name
Date of Birth Age Place of Birth
Family Doctor’s Name Telephone Number
Name of Medical Insurance Group Number
Please answer the following question:
Are you in good physical condition? Yes No If no, please explain condition(s):
Are you currently taking any medication? Yes No
Medication name, dosages, frequently:
_______
Date of last physical?
Name of health care professional who performed last physical exam?
Location where physical was done:
Special Needs: (check on the line)
Hearing Impaired Visually Impaired Learning Disability
Special Diet Physical Disability Prosthesis
Other: Explain _________________________________________________________________________________
In case of a medical emergency, who should we contact?
Name Relationship?
Parent/Guardian telephone number: Home Work
Address
Significant other, who we may also contact? Name Relationship
Page 2 of 2
Address of significant other: ___________________________ Home telephone number ______________________
Work telephone number: _______ Other telephone number _______
MEDICAL RELEASE FORM
I CONSENT TO MEDICAL TREATMENT FOR MY CHILD BY ALABAMA STATE UNIVERSITY HEALTH
SERVICES AND/OR LOCAL EMERGENCY SERVICES IF DEEMED NECESSARY BY THE PROGRAM. I
UNDERSTAND THAT I WILL BE NOTIFIED OF ANY ILLNESS OR EMERGENCY SITUATION RELATED TO MY
CHILD AS SOON AS POSSIBLE AND ACCEPT FULL RESPONSIBILITY FOR ANY UP FRONT CO-PAYMENT AND
MEDICAL BILLS THAT MAY RESULT.
Signature of Parent/Guardian Date
Signature of Student Date
Revised 1/19
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MEDICAL INFORMATION AND RELEASE FORM Students Name Date (Alabama State University)

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Completed 16 August 2020

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