Medical Treatment Authorization For Michigan State University
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1Program __________________________________________________________________________________________
Dates Attending ____________________________________________________________________________________
MEDICAL TREATMENT AUTHORIZATION FOR
MICHIGAN STATE UNIVERSITY
Your child will be involved in a Michigan State University program on the above date(s). This form must be completed and
signed by a parent or guardian to give a medical facility permission to treat the participant for minor injuries or medical
problems. In the event of serious injury or illness, the parent or person designated will be contacted. Treatment will proceed
before contacting the parent or person designated only if the situation is urgent and does not permit delay.
Participant's full legal name:
______________________________________________
Birth date: _______________________________________
Last
First
M.I.
Parent phone: day (
) ________ evening: (
) _________
Mailing Address: ________________________________
Primary care physician's name: _______________________
______________________________________________
Physician’s phone: _________________________________
______________________________________________
Physician's address: ________________________________
HEALTH INSURANCE INFORMATION:
Policy holder's name and relationship to participant ________________________________________________________
Policy holder's address: ______________________________________________________________________________
Please attach a photocopy of both sides of your insurance card OR complete the information requested below.
Insurance company name and address:
_______________________________________________ Insurance company phone number: (____) _______________
_______________________________________________ All policy numbers (please identify): ____________________
___________________________________________________________ _____________________________________________________________
If you have HMO insurance, please list the emergency treatment authorization phone number: (____) _________________
Employer's name and address:
Business phone (____) ______________________________
_______________________________________________
_______________________________________________
INFORMATION NEEDED ABOUT PARTICIPANT: Please check yes or no. If yes, explain below or on another sheet if you
need more room.
YES
NO
Does the participant have any chronic health problem or illness?
____
____
______________________________
Does he or she have any acute illness now?
____
____
______________________________
Has the person been treated recently for some medical problem?
____
____
______________________________
Does he or she have any allergies?
____
____
______________________________
Does he or she have any allergies to medication or local anesthetics? ____ ____
______________________________
Date of his or her last tetanus shot ____________________
List any medications he or she is now taking for treatment of any medical problem._________________________________
__________________________________________________________________________________________________
OFFICIAL AUTHORIZATION FOLLOWS:
I (parent or legal guardian), ____________________________________, recognize that while attending this program,
medical treatment on an emergency basis may be necessary for my child, and I further recognize that the program director
may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such
emergency care, including hospital care, as may be deemed necessary under the circumstances and to assume the
expenses of such care. I also authorize the medical facility to release any and all information required to complete insurance
claims and also authorize insurance payment directly to the medical facility.
__________________________________________________
___________________________________________
Signature of Parent/Guardian or of participant aged 18 and up
Date
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