UB SPPS Pharmacy Summer Institute Health and Release Form

UB SPPS Pharmacy Summer Institute
Parent/Guardian Consent, Medical Release & Release from Liability Agreement

Please carefully read, complete and sign the following form and mail to: Jennifer Rosenberg, 270 Pharmacy Building, SPPS – Buffalo, New York 14214-8033 no later than July 1.

Pharmacy Summer Institute

Student Email Address

Student First Name

Student Preferred Name

Student Middle Name

Student Last Name

Student Birthdate

Student Phone (10 digits with area code)

Mailing Address

Country

Street

City

Region

Postal Code

In consideration for allowing Participant to participate in a Pharmacy Summer Institute, I/we, as parents and/or guardians of Participant, agree to the following:

Authorize Participant to participate in the Pharmacy Summer Institute for the dates stated above.
Release, indemnify and hold harmless the University at Buffalo SPPS Pharmacy Summer Institute from any and all damages, except for damages caused by the sole gross negligence or intentional misconduct of the University at Buffalo, arising out of the participation of Participant in the Institute.
Prior to the commencement of the Institute, I/we were made aware of the nature of the Institute, had sufficient opportunity to inquire further, and understand the Institute has inherent risks and I/we and Participant assume, on behalf of Participant, all those inherent risks.
While participating in the Institute, Participant is subject to the policies, rules and regulations of the University at Buffalo Pharmacy Summer Institute. Possession of fireworks, explosives, any weapon, illegal drugs or alcohol is prohibited and cause for immediate expulsion from the Institute. Further, any Participant repeatedly disobeying University policies, rules or regulations may be expelled from the Institute.
Authorize University at Buffalo Pharmacy Summer Institute, its employees, clinicians, athletic trainers, nurses and agents (collectively, “Activity Sponsor”) the authority to seek, obtain, and approve any medical care and treatment including, but not limited to x-ray examination, anesthetic, medical, dental or surgical diagnosis, or treatment and medical care which may be recommended and provided under the general supervision of any physician or surgeon, for Participant which, in their judgment, is necessary for the health and well-being of Participant during his/her participation in the Institute. I/We further agree that I/we are(am) solely responsible for any costs incurred and agree to hold the University at Buffalo, their employees and agents (collectively, “University”) harmless for any liability arising out of any good faith action taken in obtaining medical treatment for Participant.

The above agreements are binding upon us, our estates, heirs, representatives and assigns.

By typing your name(s) and date(s) on this document and submitting this form, you are electronically signing this document and you agree your electronic signature is the legally binding equivalent to your handwritten signature, and you are also confirming that you are the individual named in the electronic signature, and that you are authorized to sign this document.

Applicant's Signature

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Signature

Today's Date

Health Insurance Information Sheet (required for all attendees)

Private insurance information must be provided, if applicable. Please be advised that, should a participant require medical attention, you are responsible for paying any costs not covered by insurance.

Insurance Company Name

Effective Date

Address of Insurance Company

City

State

Zip Code

Phone # of Insurance Company

Group #

Policyholder's Name

Policy #

Policyholder's Address

Policyholder's City

Policyholder's State

Policyholder's Zip

Relationship to Participant

Employee #

Contract #

I hereby authorize the release of any medical information which might be needed in connection with payment for medical services.

I request that payment under my medical insurance program be made directly to the provider on any bills for services rendered by that provider. I understand that I am financially responsible for all costs not paid by my medical insurance program.

By typing your name and date on this document, you are electronically signing this document and you agree your electronic signature is the legally binding equivalent to your handwritten signature, and you are also confirming that you are the individual named in the electronic signature, and that you are authorized to sign this document.

Parent/Guardian Signature

Today's Date

Parent/Guardian Signature

Today's Date

Emergency Information & Contacts

Please complete this form in its entirety. This information will be helpful in the unlikely event of an accident or sudden illness.

Personal physician contact information:

Name of Personal Physician

Physician Phone

Country

Street

City

Region

Postal Code

Person(s) to be contact in case of emergency:

Name

Relationship

Country

Street

City

Region

Postal Code

Daytime Phone (10 digits with area code)

Evening Phone (10 digits with area code)

Cell Phone (10 digits with area code)

Person(s) to be contact in case of emergency:

Name

Relationship

Country

Street

City

Region

Postal Code

Daytime Phone (10 digits with area code)

Evening Phone (10 digits with area code)

Cell Phone (10 digits with area code)

Medical Conditions

Are there any recent/current illness/injury/existing medical conditions PSI should be aware of?

Are there any restrictions or limitations that need to be placed on your child’s physical activity?

Are there any special dietary needs PSI needs to be aware of?

Are there any allergies (i.e. medications, food, insect stings, etc.)?

Please list any other concerns medical concerns you would like PSI to be aware of:

Please list any medications your child is currently taking and/or medical devices carried on their person, such as an EpiPen or inhaler: