Attachment IV



Texas State University

UPPS 05.06.03 Student Travel

Authorization for Medical Treatment for Minors



I,                                                      _, the __________________ of _____________________________,

   (name of parent/legal guardian)             (relation to child)               (printed name of child)


give the child named above permission to use transportation provided by Texas State University and to participate in this Texas State University travel-related activity. He or she has my permission to participate in all activities related to this event.


I also give permission to an authorized Texas State University representative to furnish such medical care as the child named above may require. Emergency treatment (i.e., treatment in the event of serious illness or injury, or the need for hospitalization or major surgery, is also granted). The Texas State representative will use all reasonable efforts to contact the emergency reference names herein. Failure of such efforts, however, should not prevent the representative from providing such medical or emergency treatment as may be necessary for the best interest of the life of the child named above. I further understand and agree that Texas State University is not liable, financially or otherwise, for any costs incurred as a result of such medical or emergency treatment provided to the child named above.


Please complete the section below.


Name of Insurance Company:_______________________________  Policy #_____________________


Name of Family Physician:__________________________________  Phone #____________________


In case of emergency, contact ___________________________________________________________


Work #____________________ Home #_____________________ Relation to child________________



Second Contact ______________________________________________________________________

Work #____________________ Home #_____________________ Relation to child________________



___________________________________              __________________________________________

Date                                                                            Printed Name (Parent or Legal Guardian)




                                                                                    Signature (Parent or Legal Guardian)