__________________________________________________ __________________________
WICHITA STATE UNIVERSITY
MEDICAL RELEASE AND AUTHORIZATION
(To be completed by parent/guardian)
MEDICAL RELEASE AND AUTHORIZATION
I authorize the Student Health Center at Wichita State University to provide my child/ward with
emergency medical treatment when needed and to provide any necessary routine and emergency
medical care while _______________________________________________________________
Name of Student
is a student at Wichita State University and under the age of 18. Furthermore, I will not in any way hold
Wichita State University or the Student Health Center responsible for any treatment or costs deemed
necessary for medical services.
Parent/Guardian Signature Date
This form was prepared for:
Family Name of Student: ___________________________________________________
Given Name(s) of Student: __________________________________________________
Wichita State University Identification Number: _________________________________
Date of Birth of Student (Month/Day/Year): ____________________________________
Please complete and return this form as soon as possible.
• To send by fax: Complete the form and send to (316) 978-3517.
• To send by mail: Office of Student Health Services
1845 Fairmount
Wichita State University
Wichita, Kansas 67260-0092
USA
N
ote: It is understood and intended that a telefacsimile transmission, scanned or photocopied copy of
the original shall be of the same legal effect as the original.
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