Authorization to Treat

Name 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