Authorization to Treat Name of Student(Required) First Middle Last Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Authorization Email Address(Required) Name of ParentIf student is under age 18 First Last 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) Yes Permission to inform parents/guardians Check here if you also give permission to inform the following parents/guardians of any medical situations. Parent Name First Last PhoneParent Name First Last PhoneI understand that I may revoke this authorization in writing at any time. Yes Student Name First Middle Last Parent Name (if student is under age 18) First Middle Last DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHA Δ
