HEALTH HISTORY MEDICAL RELEASE

HAMPTON UNIVERSITY

132 William R. Harvey Way • Hampton, Virginia 23668 • Phone (757) 727-5315 • Fax (757) 728-6612 • Email: healthcenter@hamptonu.edu

Participant's Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Father/Guardian's Name

Business Phone

Cell Phone

Home Phone

Email Address

Mother/Guardian's Name

Business Phone

Cell Phone

Home Phone

Email Address

lf not available in an emergency please notify:

Emergency Contact Name

Relationship

Emergency Contact Business Phone

Emergency Contact Cell Phone

Emergency Contact Home Phone

My child is currently taking medications:*

YesNo

Med #1 Name

Med #1 Dosage

Med #1 Reason

Med #2 Name

Med #2 Dosage

Med #2 Reason

My child has Medication Allergies*

YesNo

List Medication Allergies

My child has Food Allergies*

YesNo

List Food Allergies

My child has other Allergies*

YesNo

List Other Allergies

(Include insect stings, hay fever, asthma, etc.)

My child is under the care of a physician for the following condition*

YesNo

List Conditions (Physician)

My child has medical conditions the school/chaperones should be aware of:*

YesNo

List Conditions (School/Chaperones)

Date of last Tetanus Immunization*

DATES COVID VAX

#1 Dose COVID VAX*

#2 Dose COVID VAX

#3 Dose COVID VAX

Please be aware that few doctors will direclly bill out of state patients.

Carrier*

Group #*

Policy #*

I.D. #*

Carrier Address*

Insured*

Relationship to Insured*

REGARDING HAMPTON UNIVERSITY UPWARD BOUND/GERBER TOURS

(Must be signed for your child to participate on the field trip)

I hereby give permission to my child's sponsoring organization (i.e. school)/chaperones to provide routine health care, administer
prescribed medications, and seek emergency medical treatment including ordering x-rays and routine tests. I agree to the release of
any records necessary for treatment, referral, billing, or insurance purposes. I give permission to my child's sponsoring
organization/chaperones to arrange necessary related transportation for my child. ln the event I can not be reached in an emergency, I
hereby give permission to the physician selected by my child's sponsoring organization/chaperones to secure and administer
treatment, including hospitalization, for the person named above. I understand that none of the tour company, the sponsoring
organization or the chaperones are responsible for the quality of any such medical treatment.

Signature*

Date*

Date

NNPS ID#

HEALTH HISTORY MEDICAL RELEASE

Part 1

Part 2

Part 3

Part 4