Intercollegiate Athletics Policy Manual
4.00 Camp Policy Manual
APPENDIX - Medical 15.30.7 Consent Treat Minor
Patient Name:
Medical Record #
DOB: Gender:
Provider: Date:
CONSENT FOR TREATMENT/IMMUNIZATIONS
OF A MINOR
University Sponsored Program Participant
Information and Consent
Name of Participant:
UTEID (if one has been assigned): Date of Birth:
Address (Street, City, State, Zip):
Parent/Guardian Phone Number:
Home Work
I, the undersigned, as the parent or legal guardian of __________________________________________________ (a minor) hereby authorize such diagnostic, medical and/or surgical treatment of such minor as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury of the minor. The attending physician, appropriate staff, and The University of Texas at Austin and its officers, regents, and employees shall not be responsible in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incident to such diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their ability.
Signature of Parent/Legal Guardian Date
Print Name
Medical Information Related to Minor
Allergies:
Current Medications:
Date of Last Tetanus Booster:
Pertinent Medical History:
Insurance Company: Policy Number:
Please Return to Program Coordinator:
Name of Program:
Name of Program Coordinator: Coordinator’s Fax:
Coordinator’s Address (Street, City, State, Zip Code):
last updated: February 11, 2009