LIU Summer Honors Consent

Consent Form

Student Info
(Please verify before proceeding)

Student First Name

Student Last Name

Student ID

Student Email

Emergency Medical Care

Following any emergency medical care rendered, my child may be released to the following people:

Emergency Contact 1:

Name

* * *

Country

Address

Home Phone

Cell Phone

Work Phone

Emergency Contact 2:

Name

* * *

Country

Address

Home Phone

Cell Phone

Work Phone

Health Insurance Information:

Physician Name:

Physician Phone

Country

Address

Allergies:

Medications:

Other medical issues:

Last Tetanus shot:

Primary Insurance Company:

Policy Holder’s Name:

Policy Holder’s ID#:

Parent’s/Guardian’s Electronic Signature:

Date:

Please enter today's date

Enter the code shown:

Please enter the code shown

Submit Consent Form

Consent Form

Student Info (Please verify before proceeding)

Emergency Medical Care

Following any emergency medical care rendered, my child may be released to the following people:

Emergency Contact 1:

Emergency Contact 2:

Health Insurance Information:

Student Info
(Please verify before proceeding)