MEDICAL INFORMATION FORM

Transcription

1 SONOMA STATE UNIVERSITY SUMMER BRIDGE PROGRAM MEDICAL INFORMATION FORM In the event of an illness or injury the medical staff will need the following information to properly treat you. If you are a minor, under the age of 18, a parent or guardian must sign th form on pages 2, 3, 5 and 6. Please fill out all pages completely or the forms will be returned to you delaying your registration to the Summer Bridge Program. You will NOT be able to attend Summer Bridge unless the completed forms are on file. Send Completed Form To: Sonoma State University EOP Office, Salazar East Cotati Avenue Rohnert Park CA Fax: (707) Student s Name Date of Birth Age Address Street City Zip Telephone ( ) Last 4 digits of SSN In the event of an emergency, person to be notified (must be family member and 21 years of age or older): Name Relationship Home Telephone ( ) Work Telephone ( ) MEDICAL CARE 1. Do you have Health Insurance Coverage? If Yes, Name of Insurance Plan Plan Number 2. Do you receive MediCal Health Insurance? If Yes, Plan Number 3. Do you have a personal doctor to contact in a medical emergency? If Yes, name of Doctor Phone ( ) Address Street City Zip 4. Do you receive medical care from a clinic? If Yes, name of Clinic Phone ( ) Address Street City Zip If you answered NO to items 1, 2, 3, and 4 above, how does your family handle medical care? Page 1

2 SONOMA STATE UNIVERSITY SUMMER BRIDGE PROGRAM MEDICAL INFORMATION FORM Are you allergic to any foods or medications? (If yes, list them and attach doctor s medical statement) List any prescribed medication(s) you are presently taking and the reason(s) you are taking the medication(s): Medication Reason List special medications you must have in an emergency Do you have or have you ever been treated for any of the following: Epilepsy (seizures) Diabetes Heart Disease Hearing Impairment Sight Impairment Tuberculosis Severe Asthma Severe Allergic Reaction Major Physical Disability Other major illness/injury(s) for which you are still being treated Do you require the use of a wheelchair on an on-going basis? Have you ever or are you being treated for a mental illness? If you answered yes to any of the above, please provide details and dates: Do you have any other physical or medical limitations? If you answered yes, please explain: I CERTIFY THAT THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE. Signature of Student Print Name of Student Signature of Parent/Guardian (if student is a minor under 18 years) Print Name of Parent/Guardian Date Date Page 2

3 SONOMA STATE UNIVERSITY SUMMER BRIDGE PROGRAM MEDICAL INFORMATION FORM Authorization to Consent for Medical Treatment of Minors (For Summer Bridge Students below the age of 18) I, the undersigned parent/guardian of, (DOB ) who is below the age of 18, and is attending the Summer Bridge Program and is or will soon be enrolled at Sonoma State University authorize the staff of SSU Advising, Career and EOP Services and the staff of the SSU Student Health Center and/or other appropriate University personnel acting under the administrative authority of Sonoma State University, to act as my agent(s) to consent to any medical diagnostic procedure, to the administration of any medical or surgical treatment, or to any hospital care needed by the above named individual when any or all of the foregoing is deemed advisable by and is to be rendered under the general supervision of any physician/surgeon licensed in California under the provisions of the Medical Practice Act. I realize that the above minor must be a regularly enrolled student* at SSU to be eligible to receive services at the Student Health Center. I realize that such services are rendered either free or at very low cost to regularly enrolled SSU students. I understand that available services are limited to the scope and hours of operation of the SSU Student Health Center. I understand that an individual may be referred to off-campus medical providers: if he/she is not a current regularly enrolled student of SSU, if the medical services needed are beyond the scope or hours of operation of the Student Health Center, or at the individual s request. I realize that individuals/families must make their own financial arrangements for off-campus health care. *A regularly enrolled SSU student is selected through the regular University application and admissions process (and typically is responsible for paying regular University Registration Fees including the Student Health Fee). Printed Name of Parent or Legal Guardian Signed: Signature of Parent or Legal Guardian Date Street Address City / State / Zip Phone Home ( ) Work ( ) Page 3

4 Campus Recreation at Sonoma State University RELEASE OF LIABILITY - PROMISE NOT TO SUE ASSUMPTION OF RISK - AGREEMENT TO PAY CLAIMS PERMISSION TO USE VISUAL LIKENESS Activities: a) USE OF SSU RECREATION CENTER FACILITIES, EQUIPMENT, PROGRAMS, CLASSES, EVENTS AND SERVICES. b) USE OF SSU POOL FOR CAMPUS RECREATION PROGRAMS. Effective Locations and Time Periods: a) RECREATION CENTER: DURING HOURS OF OPERATION FROM THIS DATE (below) THROUGH AND INCLUDING August 31, b) SSU POOL: DURING CAMPUS REC SWIM HOURS OF OPERATION FROM THIS DATE (below) THROUGH AND INCLUDING August 31, 2013 AS WELL AS DURING ANY OTHER TIMES DURING THIS PERIOD IN WHICH CAMPUS RECREATION SPONSORS PROGRAMS/ACTIVITIES IN THE POOL. In consideration for being allowed to enter and use the Recreation Center and equipment, and participate in its activities, including use of the SSU Pool, on behalf of myself and my next of kin, heirs and representatives, I release from all liability and promise not to sue the State of California, the Trustees of the California State University, California State University, Sonoma State University, and its employees, officers, directors, volunteers and agents (collectively University ) and the Sonoma Student Union Corporation and its employees, officers, directors, volunteers and agents (collectively Auxiliary Organization ) from any and all claims, including claims of the University s or Auxiliary Organization s negligence resulting in any physical or psychological injury (including paralysis and death), illness, property damage or economic or emotional loss I may suffer because of my presence and/or participation. I am voluntarily entering and using the Recreation Center and SSU Pool. I am aware of the associated risks which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, death and/or property damage. I understand that these injuries or outcomes may arise from my own or other s actions, inaction, negligence, conditions related to the condition of the Recreation Center and SSU Pool. Nonetheless, I assume all related risks, both known or unknown to me, of my presence and participation. I agree to hold the University and Auxiliary Organization harmless from any and all claims, including attorney s fees and/or damage to my personal property that may occur as a result of my presence and/or participation in Recreation Center and SSU Pool facilities, equipment, programs, classes, events, and services. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. I grant permission for Campus Recreation staff to take, and make public, visual/audio images of me. I agree that Campus Recreation owns the images and all the rights to them. Without notifying me the images may be used in any manner or media including, but not limited to, University-sponsored web sites, publications, promotions, advertisements, and posters. I waive any right to inspect, approve, or be compensated for the use of such images. As of the date below, I am 18 years or older. I understand the legal consequences of signing this document, including that I (a) release the University and the Auxiliary Organization from all liability, (b) promise not to sue the University and the Auxiliary Organization, and (c) assume all risks associated with my presence and participation in the Recreation Center and SSU Pool. I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I have read this document, and I sign it freely. No other representations concerning the legal effect of this document have been made to me. Participant Signature: (NOTE: If under 18 years of age as of the date below, a Parent or Guardian Signature is required on Page 2.) Participant Name (Print): Date: Page 1 of 2. Page 2 required only if participant is under 18 years of age.

5 Campus Recreation at Sonoma State University UNDER 18 RELEASE OF LIABILITY - PROMISE NOT TO SUE ASSUMPTION OF RISK - AGREEMENT TO PAY CLAIMS PERMISSION TO USE VISUAL LIKENESS Page 2 of 2. Page 2 required only if participant is under 18 years of age. If Participant is under 18 years of age as of the date on Page 1, a Parent or Guardian Signature is required: I am the parent or legal guardian of the person named on the reverse side. I understand the legal consequences of signing this document, including that I (a) release the University and the Auxiliary Organization from all liability on my and the Participant s behalf, (b) promise not to sue on my and the Participant s behalf, (c) assume all risks of the Partipant s presence and participation. I allow my dependent to be present and to participate. I understand that I am responsible for the obligations and acts of the Participant as described in this document. I agree to be bound by the terms of this document. I have read this two-page document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me. Signature of Minor Participant s Parent/Guardian Date: Name of Minor Participant s Parent/Guardian (Print) Minor Participant s Name (Print) Date Minor Participant will turn 18 years old Minor Participant s SSU ID# (if applicable)

6 Visual / Audio Image Release Form Summer Bridge Program I grant permission to Sonoma State University, its employees and agents, to take and use visual/audio images of me. Visual/audio images are any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips or accompanying written descriptions. SSU will not materially alter the original images. The images may be used in any manner or media without notifying me, such as University-sponsored Web sites, publication, promotions, broadcasts, advertisements, posters and theater slides, as well as for non-university uses. I waive any right to inspect or approve the finished images or any printed or electronic matter that may be used with them. I release SSU and its employees and agents, including any firm authorized to publish and/or distribute a finished product containing the images, from any claims, damages or liability which I may ever have in connection with the taking of or use of the images or printed material used with the images. I am at least 18 years of age and competent to sign this release. I have read this release before signing. I understand its contents, and I freely accept the terms. Printed Name of Subject Signature of Subject If Under 18 Years of Age: Printed Name of Parent/Guardian Signature Please return signed form to: Sonoma State University EOP Office, Salazar E. Cotati Avenue Rohnert Park, CA Fax: (707) Page 6