Honors Symposium Medical Release Form

Last Name

First Name

Middle Name

Sex

Birthdate

Student's General Information

Student Phone Number

Student Email Address

Mailing Address

Country

Street

City

Region

Postal Code

Emergency Contact Information

Primary Guardian's Information

Relationship

First Name

Last Name

Phone

Email

Secondary Guardian's Information

Relationship

First Name

Last Name

Phone

Email

Emergency Contact (If above are unreachable)

Relation

First Name

Last Name

Phone

Email

Insurance Information

Name of Medical Insurance Company

Policy Holder

Policy #

Please provide a copy of your medical ID card

Student's Health History

Types of allergies and usual treatment for a reaction (If any)

List any medical/psychological/social problems with Date of Diagnosis/Onset

Recent Surgeries
Type of Surgery - Hospital - Year

Recent (or significant) hospitalizations or ER visits
Reason for hospitalization - Hospital - Year

List all medications currently prescribed
Name of medication - Strength (Dosage) - Frequency Taken - Reason for Taking

I consent to the above-named student to participate in Harding’s Honors Symposium. I further authorize the Honors Symposium personnel to sign documents permitting the performance of medical assistance as deemed necessary by legally licensed medical personnel at the time of illness or injury to the above student and will accept the financial responsibility for said medical assistance.

Signature of parent/guardian