Health Information Form Fall 2017

In the event of an emergency, we want to make sure we can take good care of you! When necessary, this health form will give medical professionals key information, and allow us to ensure that you get the fastest and best possible medical care. 

This information will be reviewed by the Chief Program Officer and Manager of Residential Life prior to your arrival, and will otherwise be kept confidential except in the case of emergency.



Date of Birth

















HEALTH INSURANCE INFORMATION








Release:

In the unlikely and unfortunate event that an illness or accident causes me to be in need of medical care, but incapable of providing consent for care, I hereby give permission to the College for Social Innovation and its authorized agents to secure and provide medical, dental or surgical care and or treatment, including anesthesia or surgery, as necessary to protect, preserve and safeguard my life or health. I further authorize College for Social Innovation to release the above information to facilitate medical or surgical care or the completion of a claim for health insurance. I release College for Social Innovation from any financial responsibility for the above-referenced treatment.

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