Full Name: Date of birth: Citizenship: Gender: Male Female E-mail address:
EMERGENCY INFORMATION
Emergency contact (parent): Name: Home telephone number: Work telephone number: Cellular or pager number: Emergency contact (other than parent): Name: Home telephone number: Work telephone number: Cellular or pager number:
Please include information for the person who is responsible for paying the student's medical bills (guarantor). Guarantor Name: Address: Telephone number: Date of Birth: Relationship to student: Employer: Insurance Company: Is any company or plan listed above considered Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO)? Yes No Does your insurance plan require a second opinion before surgery? Yes No
RECORD OF IMMUNIZATION
By typing our name in the box below, we hereby authorize Tusculum College and its insurance provider to inspect or secure copies of case history records, laboratory reports, diagnoses, x-rays, and other date covering previous confinements and/or disabilities. A copy of this authorization shall be deemed as effective and valid as the original. We further authorize the medical staff at Tusculum College to provide medical care. In the event that medical care is needed beyond the services that can be provided by Tusculum College personnel, we authorize Tusculum College to seek such services at a regional hospital or medical group. We also authorize the hospital to release medical information to authorized representatives of Tusculum College. We, the parents/guardians, will be responsible for the fee for such services. You may bill us for the amount due.
Student's full name: Parent(s) name: Date:
© 2003 Tusculum College Office of Admissions
Any questions about this form should be sent to mripley@tusculum.edu
