Authorization to Treat Authorization to Treat/ Release of Confidential InformationName of Student *Date of Birth *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.Permission to inform parents/guardians Check here if you also give permission to inform the following parents/guardians of any medical situations.Parent Name Phone Parent Name Phone I understand that I may revoke this authorization in writing at any time.Student Name Parent Name (if student is under age 18) Today's Date VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: