MEDICAL EMERGENCY CONTACT INFORMATION. Person to Contact First: Backup Contact (Relative or Friend): Name Relation to Participant Daytime Phone ( ) Evening Phone ( ) Name Relation to Participant Daytime Phone ( ) Evening Phone ( ) INSURANCE INFORMATION: Iowa State University does not provide health insurance for participants in this activity. ❒ Yes The above-named participant is covered by health insurance. If yes, please provide the following information for use in the event that treatment is necessary. ❒ No If no, initial this line stating that you do not have health insurance and are aware that Iowa State University does not carry any health insurance for you or your child and that you accept financial responsibility for any necessary treatment. PARENT/GUARDIAN INITIALS: Policy Holder’s Name Policy Holder’s Phone # Relation to Participant Insurance Company Name (IF KNOWN) Insurance Company Customer Service Phone # MEDICAL EMERGENCY PARENTAL PERMISSION I understand that my child must be healthy and reasonably fit in order to safely participate in this program’s activities. My child or I will inform the program leader(s) of any medication, ailment, condition, or injury that may affect his/her ability to participate safely. If an injury or other medical condition occurs during the program we will take reasonable steps to notify the emergency contacts listed. I hereby give permission to the program representative to provide routine first aid and seek emergency treatment including X-rays or routine tests. I agree to the release of any record necessary for treatment, referral, billing or insurance purposes. I understand that I am financially responsible for payment to the attending physicians or health care unit. In the event of an emergency where the Emergency Contact listed above cannot be reached, I give permission to the physician/hospital selected to secure and administer treatment for my child, including hospitalization.
MEDICAL EMERGENCY CONTACT INFORMATION. Person to Contact First: Backup Contact (Relative or Friend): Name Name Relation to Participant Relation to Participant Daytime Phone ( ) Daytime Phone ( ) Evening Phone ( ) Evening Phone ( )
