Medical Consent Form. Does your student have any health problems, physical disabilities, or other health or wellbeing concerns? NO YES (if yes, please explain) Does your student have any dietary restrictions or known food allergies? NO YES (if yes, please explain) Has your student been consulted or been treated by physicians, clinics or other medical practitioners within the last two years (other than routine checkups)? NO YES (if yes, please explain) Has your student been treated by a psychologist or other mental health practitioner for any mental, emotional, or nervous disorder within the last two years? NO YES (if yes, please explain) Further comments or further clarification you would like to add? CERTIFICATION OF HEALTH INFORMATION: I hereby certify that the information I provided and answers I have made above are true, correct, and complete to the best of my knowledge. I understand that I am responsible for updating this form with any changes and that failure to provide full, accurate personal information, especially information that might impact one’s personal safety and/or wellbe- ing, during any portion of ECSP may result in my student’s dismissal from the ECSP. RELEASE OF INFORMATION: The undersigned hereby consent to release to Christendom College the information contained in the undersigned student’s medical history forms and physician’s reports, with the understanding that these files be kept confidential. MEDICAL RELEASE: In case of medical need, the Director of Admissions, ECSP Coordinator, ECSP Counselor, or other College employee have the permission of the undersigned to admit the undersigned student to the hospital or to contract with a physician for diagnosis and/or treatment. The undersigned assume, jointly and severally, full financial responsibility for such diagnosis and/or medi- cal treatment and to indemnify Christendom College, its agents and employees against all such claims. I hereby certify that my student has no medical or other health conditions which will prevent their normal and expected participation in the ECSP. I further certify that my student has sufficient health, accident, and liability insurance to cover any bodily injury or property damage they may incur while participating in the ECSP and to cover bodily injury and property damage caused to a third party as a result of their participation in this program. In case of emergency, I can be reached at CELL # Signature: Date: Mother, Father, or Legal Guardian 5. Release Form Please check the...
Medical Consent Form. All tour participants must provide the following medical consent form to SAGU, which will be sent to participants upon having registered and paid in full.
