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Meriwether/ Talbot Counties Upward Bound Program

Authorization for Medical Treatment Form

I hereby grant permission to the Director of Upward Bound or his/her designee at Morehouse College in Atlanta, Georgia to authorized or furnish such medical care as the name student my require.  Further permission for emergency treatment, i.e., major surgery, is granted, conditional upon the understanding that the Director will exercise all reasonable efforts to contact the emergency reference from providing such emergency treatment under the care physician (s) contracted by the College, as may be necessary for the best interest of life for the named student.  I further understand and agree that Morehouse College in Atlanta is not liable, financially or otherwise, for such emergency treatment except as provided through the group medical insurance plan, and then only in the event that the name students has contracted from same prior to any emergency treatment.

Student's Name*

Parent Information

Parent 1 Name*

Parent 2 Name

Medical Information

Name of Family Physician*

The following information is required for your health file.  The information is strictly confidential and accessible only to representatives of the Upward Bound Program and the University officials.  Please complete each item fully and accurately.  THIS FORM IS NOT VALID WITHOUT PROPER SIGNATURES.

Indicate below the diseases that you have had, by inserting the year known, and "childhood" if unknown.
Do you now or have ever suffered chronically from any of the following?*
Have you ever had an emotional illness?*

Signature and Verification

I CERTFIY THAT ALL INFORMATION PROVIDED IN THE APPLICATION IS ACCURATE. I UNDERSTAND THE FALSIFYING INFORMATION WILL RESULT IN IMMEDIATE REJECTION OF THIS APPLICATION.*
Use your mouse or finger to draw your signature above
Date/Time*
Use your mouse or finger to draw your signature above
Date/Time *
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