Fillable Medical Release Form The Summer Academic Institute at (Harding University)

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Medical Release Form The Summer Academic Institute at (Harding University)

On average this form takes 26 minutes to complete

The Medical Release Form The Summer Academic Institute at (Harding University) form is 2 pages long and contains:

  • 2 signatures
  • 2 check-boxes
  • 97 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Harding University

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The Summer Academic Institute at Harding University is hosted by the
Honors College. Each program seeks to give an opportunity to students to
embark on a life-changing journey together for the purpose of growing
spiritually and academically.
Page 1 of 2
SUMMER ACADEMIC INSTITUTE
Medical Release Form
Name
Last: First: MI: M F DOB:
STUDENT’S GENERAL INFORMATION
Home Phone: Email Address:
Home Address:
City:
State:
Zip:
EMERGENCY CONTACT INFORMATION
Mother’s Info
(or guardian)
Name:
Evening Ph:
Address:
Father’s Info
(or guardian)
Name:
Evening Ph:
Address:
Emergency
Contact
(if above
are unreachable)
Name:
Evening Ph:
Address:
Relation:
INSURANCE INFORMATION
(PLEASE PROVIDE A COPY OF YOUR MEDICAL ID CARD)
Name of Medical Insurance Company:
Policy Holder:
Policy #:
PLEASE PROVIDE A COPY OF YOUR MEDICAL ID CARD
STUDENT’S HEALTH HISTORY
(PLEASE ATTACH ANOTHER SHEET IF YOU NEED MORE SPACE)
Allergies:
Type of Allergy
Date of last
reaction
Reaction you had
Usual treatment for
a reaction
List any medical/psychological/social problems Date of Diagnosis/Onset
Please go to the next page ----
The Summer Academic Institute at Harding University is hosted by the
Honors College. Each program seeks to give an opportunity to students to
embark on a life-changing journey together for the purpose of growing
spiritually and academically.
Page 2 of 2
Recent Surgeries
Type of Surgery Hospital Year
Recent (or significant) Hospitalizations or ER visits
Reason for Hospitalization
Hospital
Year
List
all
meds
Name of Medication
Strength (Dosage)
Frequency Taken
Reason for taking
Medical Release Statement
I ___________________________ (print name) consent to the above-named student to participate in
Harding’s Summer Academic Institute. I further authorize the Summer Academic Institute personnel to
sign documents permitting the performance of medical assistance as deemed necessary by legally
licensed medical personnel at the time of illness or injury to the above student and will accept the
financial responsibility for said medical assistance.
Signature of parent/guardian: Date:
Students will not be permitted to attend the Summer Academic Institute if both pages of this
medical release form are not completed in full.
Signature of Student: Date:
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Medical Release Form The Summer Academic Institute at (Harding University)

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Completed 23 July 2020

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