Medical Information Form

EMERGENCY CONTACT INFORMATION:

In case of a medical emergency, Manhattan College staff will contact the Emergency Contact(s) you designate below:

First Contact Name:

First Name

Last Name

Relationship

Home Phone

Cell Phone

Work Phone

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Second Contact Name

First Name

Last Name

Relationship

Home Phone

Cell Phone

Work Phone

Address

Address Line 1

Address Line 2

City

State

ZIP Code

MEDICAL ACKNOWLEDGEMENT AND CONSENT:

Participant does not have a physical or medical condition that would interfere with his/her ability to participate in this Program/Activity or that would endanger Participant’s health or the safety of others.

In case of illness, injury, or accident, the undersigned authorizes Manhattan College to arrange for Participant to be taken to a medical care facility to receive medical treatment. Undersigned also authorizes and gives consent for licensed health professionals to provide medical treatment and administer medication to Participant. Undersigned is responsible for any and all medical expenses, including for transportation.

Participant’s Name *

First Name

Last Name

Parent/Legal Guardian Signature*

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