Student Information First name of minor Last name of minor Date of birth of minor Contact Information Home phone number of parent/guardian Work phone number of parent/guardian Alternate emergency contact phone number Email address of parent/guardian Consent For Treatment of a Minor Who Does Not Have Legal Power to Consent I, the undersigned, as the parent or legal guardian of Student name (a minor) hereby authorize such diagnostic, medical and/or surgical treatment of such minor as may be considered necessary or appropriate under the circumstances for treatment of any illness or injury of the minor. I understand that no guarantees have been made as to the results of any of the above services. The provider, appropriate staff, and the Pennsylvania College of Technology and its officers and employees shall not be responsible in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incident to such diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their ability. This consent to treatment is given in contemplation that the above minor may from time to time appear at Pennsylvania College of Technology Health Services, for examination or treatment or both, unaccompanied by an adult, custodial parent or non-custodial parent, because of my (our) absence or unavailability. I (We) hereby authorize, request and direct you to render treatment to said unaccompanied minor, including, without limitation, diagnostic, medical, minor surgical care, x-rays, venipuncture, and other care that requires a series of treatments. Medical Information Related to Minor Medication allergies Food allergies Current Medications May current medications be taken without adult supervision? Yes No Date of Last Tetanus Booster Pertinent Medical History Please list any disability and access resources needs – vision, hearing, and mobility accommodations Expiration or Termination All aspects of this consent will be in effect until specifically terminated or modified by written notice received by Pennsylvania College of Technology Health Services at the above address, or on the date the minor becomes an adult under state law. I grant permissions to Pennsylvania College of Technology Health Services, or designees to transfer my minor child to an accredited hospital or other care facility if deemed necessary by the Pennsylvania College of Technology health provider. I authorize Pennsylvania College of Technology to bill and provide my minor child’s health information to the appropriate health insurance carrier or health plan to process claims arising from their care. My signature acknowledges that I have read and understand this consent and that any questions I have prior to signing this can be answered by calling Pennsylvania College of Technology Health Services. Parent/Guardian E-Signature (for individuals under 18) Relationship to minor Submit Leave this field blank
