Does the participant require reasonable accommodation for a disability in order to access or be part of the activities?
What Have We Forgotten to Ask? Please provide in the space below any additional information about the participant that you think important or that may affect his or her ability to fully participate in the program. Attach additional information if needed.
This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all program activities except as set forth by me and/or an examining physician. If you fail to advise WSU of a medical condition, risks to your child may increase. I understand the information on this form will be shared on a “need to k n o w ” b a s i s w i t h W S U s t a f f a n d v o l u n t e e r s . I g i v e p e r m i s s i o n t o p h o t o c o p y t h i s f o r m . I n a d d i t i o n , t h e h e a l t h c a r e p r o v i d e r h a s p e r m i s s i o n t o o b t a i n a c o p y o f m y c h i l d ’ s h e a l t h r e c o r d f r o m p r o v i d e r s w h o t r e a t m y c h i l d a n d t h e s e p r o v i d e r s m a y t a l k w i t h t h e p r o g r a m ’ s s t a f f a b o u t m y c h i l d ’ s h e a l t h s t a t u s . I voluntarily sign this authorization in consideration for permission for my child to participate in I have read it, and I understand its content and significance. . ______________________________________
______________________________________________________________ Signature of Parent/Guardian (For participant less than 18 years of age)
______________________________________________________________ Signature of Participant (For participant 18 years of age or older)
Parent/Guardians: Keep a copy for your records.
Washington State University Emergency Medical Consent
In an emergency requiring medical attention or a situation reasonably believed to be an emergency by Washington State University (WSU) authorized agents including event staff; I authorize WSU and its authorized agents to obtain emergency medical care for my child. I will be responsible for any expenses incurred in so doing including but not limited to care by health care professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
NOTE: Minors may consent to certain services in Washington.
I hold harmless and agree to indemnify Washington State University, its authorized agents and employees and the event staff from decisions to seek emergency treatment. Health-Care Providers:
Name of participant’s primary doctor(s): _______________________________
Phone: (_______) _________________
Name of dentist(s):________________________________________________
Phone: (_______) _________________
_______________________________________________________________________________ (severe allergies / life-threatening conditions / chronic illnesses)
Medical Insurance Information:
This participant is covered by family medical and/or hospital insurance
Primary Insurance Company
Insurance Company Phone Number (_____) ___________________
Name of another person to contact in case of emergency if you are not available:
Phone: (____) ______________
Relationship to participant: