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Name of Student(Required)
Date of Birth(Required)
Name of Parent
If student is under age 18
I hereby grant permission to the Beacon College Student Health Services staff to render any first aid/health care or emergency treatment to myself (son/daughter). I also grant permission for the above referenced Beacon College staff to arrange health care, emergency treatment or hospitalization at the accredited hospital or psychological facility when deemed medically necessary. I also authorize Beacon College Health Services to release confidential information regarding my care to the above mentioned health care providers.(Required)
Permission to inform parents/guardians
Parent Name
Parent Name
I understand that I may revoke this authorization in writing at any time.
Student Name
Parent Name (if student is under age 18)
This field is for validation purposes and should be left unchanged.