Fillable Medical Consent Template (Cerritos College)

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Medical Consent Template (Cerritos College)

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Cerritos Community College District
Medical Consent
In the event of any medical emergency, I grant to Cerritos College or any of its representatives
on the trip the full authority to take any action deemed necessary to protect my health and safety
at my expense, including but not limited to placing me (Participant) under the care of a doctor or
in a hospital at any place for medical examination and/or treatment, or returning me to my home
city at my own expense if such return is deemed necessary after consultation with medical
authorities.
I am 18 years of age or older and am the Participant. My birth date is: ____________________.
Signature of Participant
Date
Print Name
Student Number
Address
Phone Number
In case of emergency please contact: _______________________________________________ .
Relationship to participant: _______________________ Phone number: ___________________
Medical insurance carrier: ____________________________________________
Policy Number: __________________________________________
Please list any prescription medication: _________________________________________
_________________________________________________________________________
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Medical Consent Template (Cerritos College)

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Completed 18 July 2020

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