BrownUniversity,Box1946

Providence,RhodeIsland029129120
Tel4018633100Fax4018633955
Email:conference_services@brown.edu

MEDICALAUTHORIZATIONFORM

www.brown.edu/conferenceservices

NOTE:StudentroomassignmentsCANNOTbemadeuntilthisformhasbeenreceived.
Thisformdoesnotrequireaphysicianssignature.

STUDENTCONTACTINFORMATION
Pleaseprint
StudentsName____________________________________________________________________Gender: Male

Female

Parent/GuardianName(s)_____________________________________________________________________________________________
HomePhone:_____________________________________________Studentcell_________________________________________________
Parent/GuardianDayPhone:_________________________________Eveningphone______________________________________________
EmergencyContact:________________________________________Relationship_______________________________________________
EmergencyDayphone:______________________________________Eveningphone_____________________________________________

MEDICALHISTORY&AUTHORIZATION

INSURANCECOVERAGE:YoumustshowproofofhealthinsurancecoveragewithaUScarrier.Ifproofisnotlisted,youwillbeplacedonBrowns
studenthealthinsuranceplanforacostof$60.Thisplanhaslimitedcoverage.PleasecontacttheOfficeofSummer&ContinuingStudiesfor
moreinformation.

InsuranceCarrier____________________________________________PolicyNumber_______________________________________
CarrierAddress______________________________________________________________CarrierPhone_______________________
Nameofpolicyholder___________________________________________________________________________________________
Pleaseattachacopyofbothsidesofyourinsurancecard.

MEDICALHISTORY
1. Areyoureceivinganykindoftreatmentformedicalconditionsuchasasthma,diabetes,aheartcondition,highbloodpressure,emotional,
neurological,convulsions,other,etc.?Ifso,whatisthemedicalcondition?

2. Listanymedicationthatyoucurrentlytake:_________________________________________________________

3.

Pleaselistanyknowallergiestodrugs,food,andinsects.DoyourequireanEpiPen? YES NO

IfYES,pleaseexplain.

4.

Doyouhaveorhaveyouhadanyhistoryofthefollowing:

HeartDisease
Diabetes

HighBloodPressure

YES
YES
YES

NO
NO
NO

HighBloodCholesterol
FaintingorDizziness

YES
YES

NO
NO

Asthma
Seizures

YES
YES

YES

NO

IfYES,pleaseexplain.

NO
NO

5.

Doyouhaveanylimitingmedicalconditions(temporaryorpermanent)?

6.

Doyouhaveanyofthefollowingconditions(ifYES,pleaseexplain):
Recentinjuryorinfectiousdisease
Chronicorrecurringillness
Recentsurgery

YES NO____________________________________________________________

YES NO____________________________________________________________

YES NO____________________________________________________________

SEEREVERSESIDE
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STUDENTNAME:__________________________________

7.

Pleasedescribe,listorprovideareportorstatementforanyotherconcerns,medicalorotherwise,youwishtobringtoourattention:

EMERGENCYCONTACTINFORMATION
Intheeventofanemergency,wewillcallthestudentsparent/guardianfirstaslistedintheStudentContactInformation.Ifwecannotreachthe
parent/guardian,wewillcallthealternatecontactasdesignatedintheStudentContactInformation.(PleasebesuretoinformtheOfficeof
SummerandContinuingStudiesofanychangesduringthesummerprogram.)

AUTHORIZATIONFORTREATMENTFORSTUDENTSUNDER18YEARSOFAGE
Duringthesummer,itmaybecomenecessaryforastudentofaBrownUniversitysummerprogramtoreceivemedicalservices.Inordertoobtain
andprovideappropriatemedicalservicesunderthesecircumstances,parentalpermissionmustbeobtainedinadvanceforallstudentsunderthe
ageof18.Theparent/guardianwillbenotifiedasearlyaspossibleofanillnessorinjury,informedofthesituation,andconsultedaboutimportant
medicaldecisions.However,aseriousaccidentorinjurymayrequireimmediateactionand/ortreatmentwithoutpriornotificationtotheparentor
guardian.

Parent/GuardianAuthorization
IacknowledgethatIhaveanobligationtoprovidetherequestedmedicalinformationtoBrownUniversitySummerProgramsor
designeepriortomyson/daughter/wardsparticipationintheprogramandtodiscloseanyinjuries,orillnesses,she/hemaysufferormayhave
sufferedsubsequenttosigningthisform.Iagreetoassumeallrisksandhazardsresultingfromanyundisclosedinjuriesorillnesses.Further,I
authorizetheDeanordesignee,atanytimeandfromtimetotimeduringtheprogram,totakesuchactiondeemednecessaryordesirableformy
son/daughter/wardswelfarewhenshe/heistransportedtoahealthcarefacilityfortreatmenttoberenderedtohim/herunderthegeneralor
specialsupervisionofanurse,dentist,physician,orsurgeonlicensedtopracticeintheStateofRhodeIsland.
a. WhenthenatureandseverityoftheillnessorinjuryrequirestreatmentbeyondthecapabilitiesoftheBrownUniversityHealthServices,
inthejudgmentofHealthServicespersonnel;
b. Intheeventofanaccidentoremergencyrequiringimmediatemedicalattentionand/ortreatment.
Iagreetoassignthebenefitsofpersonalcoverageofmedicalinsuranceformyson/daughter/wardtotheappropriateprovidersofhis/her
medicalcare.Intheeventthatappropriatemedicalcoverageundermymedicalinsuranceplanisunavailable,insufficient,ordeniedwithrespectto
treatmentorservicesprovidedbyson/daughter/ward,Iherebyagreetoassumeallfinancialliabilityandresponsibilityofallexpensesandcosts
associatedwithsaidtransportationand/ortreatmentofhis/herillnessorinjury.
InconsiderationofBrownUniversitysallowingmyson/daughter/wardtoparticipateintheprogramandagreeingtointerveneonmybehalfto
provideormakearrangementstoprovidemedicalassistancetohim/herasneeded,IagreetoreleaseandindemnifyBrownUniversity,including
theCorporation,itsTrustees,faculty,employees,staff,andotheragentsformallliabilityandresponsibilityforanyclaims,demands,actions,or
otherproceedingsforanypersonalinjury,accidentdamage,expenses,orotherlosscaused,suffered,orincurredbyhim/heroranyotherperson
orentityarisingoutofhis/herparticipationintheprogram,unlesscausedbythewillfulnegligenceofBrownUniversity.
IacknowledgethatIhavereadandunderstandtheabovestatementsandthatifIamunabletodoso,forwhateverreasons,Ihavehadthem
readtomeandamconfidentthattheindividualsodoinghasreadand/ortranslatedthestatementstruthfullyandintheirentirety.

MEDICALCAREAUTHORIZATIONFORALLSTUDENTS
I,thestudent,herebyspecificallyauthorizetheBrownUniversityHealthServicesand/oranyauthorizedmemberofitsstaff,ordulyaffiliated
consultant,toprovidecareandtreatmenttothestudentandforemergencytreatment.

*Ifstudentisunder18yearsofage,parentalsignatureisrequired.

Parent/Guardiansignature:_______________________________________________________Date:___________________________

Studentsignature:______________________________________________________________Date:___________________________

RETURNTHISFORMTO:
BrownUniversity
ATTN:ConferenceServices
Box1946
Providence,RI029129120
Fax:4018633955

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