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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)
Date
This field is for validation purposes and should be left unchanged.