2019 UofA Medical Form - South Region ODP Camp

YOUTH PROGRAM MEDICAL INFORMATION FORM
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Instructions
The University of Alabama requests the information on this form so we will have accurate information in the event of an emergency. It is recommended that you consult with a physician prior to participating in this program. If the participant has a pre-existing medical condition, participation in any strenuous activity may not be recommended. You are accountable for providing an accurate medical history, but final determination about appropriateness of participation is the responsibility of you and your physician. Please answer all questions below. If the participant has any medical issue that is not specifically requested below, but which you think is important, please include that under Additional Information.
PARENT/GUARDIAN INFORMATION
EMERGENCY CONTACT INFORMATION
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Please attach a copy of the front and back of your insurance card with this form


MEDICAL INFORMATION
To request reasonable accommodations, contact the UA Office of Compliance, Ethics, and Regulatory Affairs at (205) 348-2334 or youthprotection@fa.ua.edu. Requests should be submitted in writing at least 30 days prior to the event. Late requests may not be accommodated due to time constraints. 
ADDITIONAL INFORMATION

AUTHORIZATION FOR MEDICAL CARE

I understand that my child is voluntarily participating in a program/activity at The University of Alabama. By signing this form, I hereby acknowledge that all information is accurate and current and, to the best of my knowledge, my child is capable of participating safely in this program/activity. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program/activity. I agree to notify the program/activity of any changes
in my child’s mental, physical, or medical condition before the program/activity begins. In the case of accident or illness, I hereby authorize the program/activity staff to administer or seek medical treatment for my child, as they see fit, including routine first aid care or emergency medical treatment. However, I understand and acknowledge that such staff are not medical professionals. I hold harmless and agree to indemnify the program/activity, The Board of Trustees of the University of Alabama and its agents and employees, from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment or lack thereof. I acknowledge that I am solely responsible for any hospital or other costs arising out of any illness, bodily injury or property damage sustained through my child’s participation in such voluntary program/activity. 
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* Indicates Response Required