This medical form is required for all students enrolled in the Summer Study program at the University of Colorado Boulder. It must be completed and returned to the New York office by May 1st. The form collects student information like name, date of birth, address, emergency contacts, and insurance information. It also requires a physician to provide medical history including allergies, illnesses, surgeries, medications, and activity restrictions. The physician must also sign off and a complete immunization record must be attached. Finally, the form requires parental authorization for medical treatment of students under 18 in case of emergency.
This medical form is required for all students enrolled in the Summer Study program at the University of Colorado Boulder. It must be completed and returned to the New York office by May 1st. The form collects student information like name, date of birth, address, emergency contacts, and insurance information. It also requires a physician to provide medical history including allergies, illnesses, surgeries, medications, and activity restrictions. The physician must also sign off and a complete immunization record must be attached. Finally, the form requires parental authorization for medical treatment of students under 18 in case of emergency.
This medical form is required for all students enrolled in the Summer Study program at the University of Colorado Boulder. It must be completed and returned to the New York office by May 1st. The form collects student information like name, date of birth, address, emergency contacts, and insurance information. It also requires a physician to provide medical history including allergies, illnesses, surgeries, medications, and activity restrictions. The physician must also sign off and a complete immunization record must be attached. Finally, the form requires parental authorization for medical treatment of students under 18 in case of emergency.
This medical form is required for all students enrolled in the Summer Study program at the University of Colorado Boulder. It must be completed and returned to the New York office by May 1st. The form collects student information like name, date of birth, address, emergency contacts, and insurance information. It also requires a physician to provide medical history including allergies, illnesses, surgeries, medications, and activity restrictions. The physician must also sign off and a complete immunization record must be attached. Finally, the form requires parental authorization for medical treatment of students under 18 in case of emergency.
SUMMER STUDY at THE UNIVERSITY OF COLORADO BOULDER
This Medical form is required for all enrolled students. Please return completed form to our Melville, NY
office by May 1st, or as soon as it is complete.
PART A: Parents/Guardians are to complete this part of the form. STUDENT INFORMATION Last Name Sex First Name Month Day Year MI Age Zip Code Social Security # Home Phone # Country
Male Home Address: Street
Female
Date Of Birth: City
State
PARENT/GUARDIAN INFORMATION 1ST Parents/Guardians Name 2ND Parents/Guardians Name Business /Cell Phone #
Business /Cell Phone #
EMERGENCY CONTACTS Please list below names and phone numbers of two people who can reach you at all times Name Name City, State City, State Phone # Phone # Relationship Relationship
MEDICAL INSURANCE - Please provide your insurance information
Insurance Company: (Blue Cross, Blue Shield, HMO, etc.) Policy #
PART B: Physicians are to complete this part of the form.
MEDICAL HISTORY: Please use the back of this form, if necessary, for more complete explanations.
DISEASES/CONDITIONS Asthma Seizures/Epilepsy Diabetes Other Chronic or Recurring Conditions: List any Surgical Procedures or Serious Injury: Current Medication(s): Date of Last Tetanus Shot: Activity Restrictions: Physician's Name (Print) Signature
ALLERGIES Drug: Insect: Food: Other:
MENTAL HEALTH Depression Eating Disorder Other:
Please attach a complete up to date immunization record.
Phone #
PART C: Parent/Guardian Authorization
This health history is correct so far as I know, and the person described herein has permission to engage in all activities, except as noted. I understand that all activities are engaged in at the student's free choice and release SUMMER STUDY PROGRAMS, INC. and THE UNIVERSITY OF COLORADO BOULDER of any liability resulting from accident or injury in connection with these activities. PERMISSION FOR MEDICAL TREATMENT OF A STUDENT UNDER 18 YEARS OF AGE: In the event I cannot be reached in an emergency and to avoid delay in treatment should medical problems arise, I hereby grant permission to the attending physician to evaluate, treat, secure a referral, hospitalize, order injection, anesthesia or surgery for the student named above. _______________________________________________ Parent's/Guardians Signature
NHA Phlebotomy Exam 2022-2023: Study Guide with 400 Practice Questions and Answers for National Healthcareer Association Certified Phlebotomy Technician Examination
