CENTRAL MICHIGAN UNIVERSITY

DEPARTMENT/PROGRAM:  _______________FOREIGN LANGUAGE DAY______________

COORDINATOR/CONTACT PERSON:  ____Patti Cotter______________________

CONSENT FOR MEDICAL TREATMENT OF A MINOR CHILD OR DEPENDENT ADULT

Attention Parents/Caregivers:  The information and consent requested here will make a medical situation easier for your child or dependent adult in case an accident or illness occurs when he/she is on campus and you are not immediately available.

Remember:  Life and limb threatening emergencies will always be treated even when consent is unavailable.  This form is necessary for other situations such as stitches, broken bones, and minor illnesses where treatment is normally withheld until parental consent is obtained.

I, _____________________________________________________ who reside at

______________________________________________________ do hereby state

that I am the parent or legal guardian of the following minor child/dependent adult who resides with me:

______________________________________________________________________
 Print Name                                       Age        Birthdate

I authorize Central Michigan University Health Services and/or Central Michigan Community Hospital to provide necessary and emergency care for the above mentioned minor child or dependent adult during the period that he/she is on campus attending a CMU sponsored program.  I consent to the performance of such medical and/or surgical procedures which are necessary or advisable from:

_____________________________ through ________________________________
  Month     Date     Year                  Month     Date     Year

I agree to be financially responsible for the services provided.  I authorize the release of information to my insurance company and my personal physician.

__________________________________  __________________________________
Signature of Parent or Guardian                      Date

I can be reached at __________________________________________________
                        Home                           Work

PLEASE COMPLETE THE MEDICAL HISTORY INFORMATION ON THE REVERSE SIDE OF THIS SHEET.   MEDICAL HISTORY OF CHILD/DEPENDENT ADULT

_________________________________ ____________________________________
Name of child/dependent adult            Social Security Number

_________________________________ ____________________________________
Age           Birthdate                      CMU Program

Please list any allergies, current medical problems, chronic diseases, and any medicines now being taken:  ( Please print )

ALLERGIES: ___________________________________________________________

MEDICAL PROBLEMS: ____________________________________________________

                  ____________________________________________________

CHRONIC DISEASES: ____________________________________________________

                  ____________________________________________________

CURRENT MEDICATIONS:  ________________________________________________

FAMILY PHYSICIAN:  _________________________PHONE:____________________

OFFICE ADDRESS:  _____________________________________________________

______________________________________________________________________

INSURANCE COMPANY or GOVERNMENT PROGRAM: _____________________________

__________________________________  __________________________________
Policy or I.D. Number                Phone Number to Authorize Payment
       
Subscriber:  _________________________________________________________
              Name                         Address

Relationship to child/dependent adult: _______________________________
 
___________________________________  _________________________________
Signature of Person Completing Form          Date   PLEASE COMPLETE THE CONSENT TO MEDICAL TREATMENT ON THE REVERSE SIDE OF THIS SHEET.