Treatment Authorization must be signed by a parent or guardian if student is under 19

I hereby authorize and give my consent to the Health authorities of Union College or any licensed physician to perform upon or administer to
(Name of Student)__________________________________________ any resonably necessary medical or surgical treatment. I also give permission to administer whatever anesthetic may be necessary or advisable during the medical or surgical procedures. This authorization is intended to cover emergency treatment, immunizations, injections, and minor operations and procedures. In the event of indicated major surgery, or major treatment, the College Authorities or physicians are not hereby excused from attempting to contact me before relying upon this authorization. This authorization does not entitle the service or physician to render any medical or surgical treatment without the student's personal consent, unless the student is unable to give consent (i.e. unconsciousness). Permission is also granted to release information from the student's medical record to person or person's designated by the college when, in the opinion of the Director of Student Health Service release of specific information is deemed necessary. This permission is good only while the student is attending the above college and only until the student has attained his nineteenth birthday.

Signature ________________________________________________________ Date _________________________________

Relationship to student __________________________________________ Address _______________________________