Riverside Community College District
Health Services
PERMISSION TO TREAT A MINOR/EMERGENCY INFORMATION
I (parent/legal guardian) grant permission and authorize the administration of all diag
nostic and
therapeutic treatments that may be considered advisable or necessary in the judgment of the
physician/nurse practitioner/registered nurse/counselor at Riverside Community College District's
Health Services.
Student Printed Name
Student ID Number
Printed Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian
Date
Address
Street
City
Zip Code
EMERGENCY INFORMATION:
In case of emergency please
contact:
Name
Relationship
Phone Home
Work
Cell
Allergies:
Serious Medical Conditions:
Medications:
All medical information and records are subject to guidelines of the Health Insurance
Portability and Accountability Act (HIPPA).
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