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CVCU STUDENT INFORMATION FORM

PERSONAL INFO

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EMERGENCY CONTACT / MEDICAL RELEASE

In the case of a medical emergency during which the parents cannot be reached, CVCU administration requires the following information to be on file.

EMERGENCY CONTACT #1

EMERGENCY CONTACT #2

MEDICAL INFORMATION

Though every attempt will be made to reach the parent or emergency contact in the event of an emergency, should the need arise, I, the undersigned hereby authorize and consent to any X-ray examination, anesthetic, and medical or surgical diagnosis rendered under the general or special supervision of any member of the medical and emergency room staff licensed under the provisions of the Medicine Practice Act, a Dentist licensed under the provisions of the Dental Practice Act, and the staff of any acute general hospital holding a current license to operate a hospital from the state of California Department of Public Health.

I understand that this authorization is given in advance of any specific diagnosis and is given to provide authority and power to render care that the aforementioned physician in the exercise of his or her best judgment. I understand that effort shall be made to contact the undersigned prior to rendering treatment, but that any of the above treatments will not be withheld if the undersigned cannot be reached. I will not hold liable any CVCU campus, faculty, staff, or volunteers for medical aid rendered and agree to reimburse CVCU for medical or other expenses incurred in this care.

SIGNATURE

I affirm that the above answers are true and accurate to the best of my knowledge

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