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Medical Authorization

NMSU-Carlsbad Sponsored Youth Program

MEDICAL INFORMATION AND STATE TREATMENT AUTHORIZATION

 

No Participant programs, events, camps or retreats for minors, sponsored by New Mexico State University (NMSU), prior to the completion of this form by a custodial parent or a legal guardian. Additional pages may be attached if needed.

 

Participant Name:____________________________________________

 

Name of Custodial Parent(s) or Legal Guardian: _______________________

 

Physical Home Address:_______________________________________

 

Local Address (if different):_______________________________________________________

 

Participant Phone No.:_______________________________________________

 

Age:_______________________________________________________

 

Birth Date:______________________________________________

 

 

Emergency Contact Information:

 

Emergency Contact Name: _________________________________________

 

Phone Numbers:_________________________________________________________

 

Alternate Emergency Contact:_______________________________________

 

Phone Numbers:_________________________________________________________

 

Personal Physician Primary Care Information:

 

Physician Name:_________________________________________________________

 

Phone Numbers:__________________________________________________________

 

Health Insurance:- Insurance Company Name:_________________________________

 

Name of Policy Holder: ____________________________________________________

 

Identification No.:_________________________________________________________

 

NMSU PERSONNEL RECEIVING COMPLETED MEDICAL INFORMATION FORMS ARE RESPONSIBLE FOR CONFIDENTIALTY OF INFORMATION AND WILL SHRED FORMS AT PROGRAM CONCLUSION, UNLESS MEDICAL TREATMENT WAS PROVIDED

NMSU Sponsored Youth Program Medical Information and Authorization - UGCver04232019 Page 1 of 2

Participant's Immunizations:

List immunizations which are not current:________________________

__

_________________________________________________________________

 

_________________________________________________________________

 

 

Date of most recent Tetanus vaccination:_______________________________

 

Participant Medical Background

Special services required due to physical or medical condition:

 

__________________________________________________________________

 

Restrictions on physical activities:______________________________

 

__________________________________________________________________

 

Medications (prescription and over the counter) currently taken, including dosage and frequency:______________________________________________________________

 

_______________________________________________________________________________________

 

Describe any assistance needed with medication management:

 

_______________________________________________________________________________________

 

 

Vision — does Participant utilize glasses or contact lenses?

 

___________________________________________________________________

 

Dietary Restrictions:

 

____________________________________________________________________

 

 

Allergies (medications, foods, insects, plants:

 

 

Medical History - mark any that apply to participant.

 

Heart Disease _______

Epilepsy ____________

Diabetes ______________

Asthma ______________

Blood Pressure ______

 

Other medical information of which NMSU should be aware:

 

_________________________________________________________________________

 

_________________________________________________________________________

 

_________________________________________________________________________

 

By signing below, I represent that I am a custodial parent or legal guardian of the Participant indicated above, who is under the age of 18, and that the information provided above is accurate. My signature also represents my permission for treatment by a licensed physician (if medical treatment is deemed necessary by the physician) and my acceptance of complete financial responsibility for all medical services rendered to the Participant.

 

Parent or legal guardian ___________________________________________________

 

Printed Name of Parent or Legal Guardian___________________________

 

Date __________________

 

 

NMSU PERSONNEL RECEIVING COMPLETED MEDICAL INFORMATION FORMSARE RESPONSIBLE FOR CONFIDENTIALTY OF INFORMATION AND WILL SHRED PROGRAM CONCLUSION, UNLESS MEDICAL TREATMENT WAS PROVIDED.

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NMSU Sponsored Youth Program Medical Information and Authorization - UGCver04232

NMSU does not discriminate on the basis of age, ancestry, color, disability, gender identity, genetic information, national origin, race, religion, retaliation, serious medical condition, sex (including pregnancy), sexual orientation, spousal affiliation or protected veteran status in its programs and activities as required by equal opportunity/affirmative action regulations and laws and university policy and rules. All complaints of discrimination should be made to the Office of Institutional Equity at equity@nmsu.edu or through the OIE website at https://equity.nmsu.edu/notice-of-non-discrimination/