DMA Summer Camp Packet - Baton Rouge Community College

BATON ROUGE COMMUNITY COLLEGE
Continuing Education
Youth Medical Form
It is a necessity to receive the completed form before your child's program begins.
To Parents: In order for your son/daughter to receive medical care in the event of illness or injury while participating
in a BRCC program, please give the following information:
Consent for minors attending special programs through BRCC to receive required medical treatment.
Student's Name___________________________________Date of Birth___________________________
SS Number ___________________________
(Required)
EMERGENCY CONTACT INFORMATION:
Name: ________________________________________ Relationship: _________________________
Phone: Wk: _____________________
Hm: _____________________ Cell ___________________
Fax: ____________________
E-MAIL Address : ___________________________________________
Insurance Company & Policy Number_____________________ Name of person carrying Insurance______________________________
Place of Employment _______________________________
Family Physician: Name________________________________Phone Number: ______________________
Address ______________________________City _____________________State _________Zip__________
List any medical condition(s) that you would like BRCC/Continuing Education to know in order to attend to
your child:
List all known allergies, medications or foods to which your child is allergic:
List any special accommodations that your child my require to participate in this program:
BRCC STAFF WILL NOT ADMINISTER ANY MEDICATIONS TO YOUR CHILD/CHILDREN
Medical Treatment Consent and Liability Release:
I, parent/guardian, grant to BRCC/ Continuing Education or any of its representatives, full authority to take action deemed
necessary to protect the health and safety of my child at my expense, to include but not limited to placing said child under
the care of a doctor, EMS personnel, or in a hospital for medical treatment if necessary.
I have read the foregoing and understand its terms, and I fully agree to all the provisions set forth therein.
Parent/guardian name (print)
_____________________________________
Parent/Guardian Signature
__________________________________