Attachment V

 

TEXAS STATE UNIVERSITY-SAN MARCOS

Authorization for Medical Treatment

 

Name: _____________________________________SSN#: _____________________________

 

I give my child permission to use transportation provided by Texas State University-San Marcos and to participate in this Texas State University-San Marcos travel-related activity. He/She has my permission to participate in all activities related to this event. 

 

I also give permission to an authorized Texas State University-San Marcos representative to furnish such minor medical care as my son/daughter may require. Further emergency treatment, i.e. treatment in the event of serious illness/injury or the need for hospitalization and/or major surgery, is granted, conditional upon understanding that 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 emergency treatment under the care of the physicians contacted by the representative of Texas State as may be necessary for the best interest of the life of the student listed above. I further understand and agree that Texas State are not legally liable, financially or otherwise for such emergency treatment (minor or serious).

 

Please complete the section below.

 

Name of Insurance Company:__________________________________  Policy #_____________

 

Name of Family Physician:____________________________________   Phone #_____________

 

In case of emergency, contact______________________________________________________

 

Work#____________  Home#____________ Relation to student __________________________

 

Second Contact_________________________________________________________________

 

Work#_____________ Home#____________ Relation to student__________________________

 

_______________________                          ___________________________________________

Date                                                                            Signature (Parent or Guardian)