Last Name: _________________________ First Name: _________________________
Date of Birth: __________ Student I.D. #: ____________ Home Phone: ____________
Street Address: _____________________ City: ______________________ Zip:_______
________________________ _______________ _______________ ____________
Father’s/Guardian Name Phone # Work # Cell Phone #
________________________ _______________ _______________ ____________
Mother’s/Guardian Name Phone # Work # Cell Phone #
A local contact person in case of illness or injury if parent/guardian cannot be reached:
Name: _________________ Relationship: ____________ Phone #: ____________
Physician’s Name:_____________________ Phone #__________
Medical Insurance:___________________Subscriber #__________
Please list any medical conditions we should know about in an emergency.
_____________________________________________
Are there medications the student takes regularly? __No __Yes Please List:
____________________________________________________________
Does the student have any allergies to medications or other substances?
Please List:___________________________________________________
Students seeking
emergency care, birth control,
pregnancy testing, or
STD/ HIV screening and care
are considered by law to be
mature minors with the right to consent
for these specific medical services
.
I, the undersigned parent/guardian of _______________________________, hereby authorize the Medical and
counseling staff of San Bernardino Valley College (SBVC) Student Health, as agent of the undersigned to consent
to any diagnostic procedure (including x-rays), to the administration of any counseling, medical, surgical treatment,
or to any accredited hospital when any or all of the foregoing is deemed advisable and is to be rendered under the
general Supervision of any Physician or surgeon licensed under the provisions of the Medical Practice Act.
I ___DO ___ DO NOT grant the staff of the SBVC student health permission to give the above named student
over the counter medication for symptom relief if they are unable to reach me for verbal consent.
This authorization is given in advance of any specific diagnosis, treatment or medical care being required and
pursuant to the provisions of Section 25.9 of the California Civil Code.
It shall remain in effect throughout the term designated on this form.
X_______________________
Date: ______________
