Medical Information and Authorization
PARENT/GUARDIAN AUTHORIZATION AND RELEASE
PARTICIPANTNAME:___
I authorize Kentucky State University and YEA staff to provide routine healthcare or first aid, administer medications as listed, and seek emergency medical treatment if necessary.
I understand that:
I am responsible for any medical expenses incurred
I will be notified in case of emergency
Parent/Guardian Name (print): ___
Signature: ___
Date: ___
___
Medications Received By: ___
Date: ___
Notes: ___
Kentucky State University is an equal opportunity provider.