MEDICAL/MENTAL HEALTH AUTHORIZATIONS:
PERMISSION FOR TREATMENT
* Consent is given for treatment in the University Student Health Service by licensed personnel for
routine health (physical or mental) care, assessment, treatment, and if necessary, referral or
* If health care is needed in the absence of a Health Service Personnel, a college representative may
choose local medical personnel on my behalf.
* No guarantee has been made to me as to the results to be obtained by treatment given to me.
* It is understood that the University will contact the designated, authorized person(s) in the case of an
emergency or serious illness (physical or mental).
* I understand that I will be responsible for charges incurred due to illness, injury or accident.
Student ID Number
Please print this form, sign, and mail it to : JBU Campus Nurse
2000 West University St.
Siloam Springs, AR 72761
(If over 18 years of age)
Parent or Guardian
(If student is NOT 18 years)