Medical Information and Authorization PARENT/GUARDIAN AUTHORIZATION AND RELEASE

PARTICIPANTNAME:___

SECTION 6. MEDICAL AUTHORIZATION

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: ___

___

FOR PROGRAM/CAMP STAFF USE ONLY

Medications Received By: ___

Date: ___

Notes: ___

Kentucky State University is an equal opportunity provider.