EMERGENCY INFORMATION FORM

Please fill out the form completely.

EMERGENCY INFORMATION

Please enter Emergency Contact Information (Parent/Guardian)
Please enter at least one Emergency Contact.

FIRST PARENT/GUARDIAN

SECOND PARENT/GUARDIAN

MISSING PERSON EMERGENCY CONTACT

(Only if different from above, this name will be called in place of the above name in the event a student were to become a missing person.)

INSURANCE INFORMATION

HEALTH HISTORY

Please check the applicable boxes.

STUDENT TREATMENT CONSENT

In case of serious illness or accident, I give Tusculum University (or its representative) permission to secure medical and/or surgical care to include transportation to a doctor or hospital of their choice, injections, examination, medication, and surgery that is considered necessary for my good health. I agree to pay all costs associated with my medical care.

All statements in this medical record are true to the best of my knowledge and belief. Should any change in my health status occur, I understand Student Affairs should be notified in writing.

AUTHORIZATIONS

In accordance with HIPAA and other confidential provisions, and in order to provide continued and appropriate medical care, I give Tusculum University or its representatives permission to release personal health information to health care professionals/medical facilities.