COSMOS-UCI
Medical Emergency Authorization
& Release Form
Cluster #_________
Students and Parents/Guardians please carefully read and agree to the terms and conditions outlined in this
document for participation in COSMOS. Do not leave any sections blank.
CONTACT INFORMATION (please print)
Student
First Name
Middle Name
Male
Last Name
Number/Street
City
State
Home Phone Number
(
)
Cell Phone Number
(
)
Zip
Date of Birth
______/______/______
Age
Email Address
Parent/Guardian
First Name
Number/Street
Home Phone Number
(
)
Employer
Middle Name
Last Name
City
Cell Phone Number
(
)
Female
State
Zip
Work Phone Number
(
)
Position
E-mail address
Parent/Guardian
First Name
Number/Street
Home Phone Number
(
)
Employer
Middle Name
Last Name
City
Cell Phone Number
(
)
State
Position
Zip
Work Phone Number
(
)
E-mail address
RELEASE INFORMATION
List persons other than parents who are authorized to pick up student. COSMOS staff will release student only to
authorized individuals.
Name
Relationship
Phone Number
(
)
(
)
(
)
(
)
INSURANCE INFORMATION
If your child needs immediate treatment, he/she will be taken to Kaiser Permanente, Hoag or the Newport Urgent
Care. If your child is treated, you will be billed directly and will then have to seek reimbursement from your
insurance carrier. You will be responsible for any charges incurred. Outside Medical Facilities like the Irvine Medical
Center do honor insurance plans but will only be used during after-hours emergencies. You will be contacted
regarding any needed medical attention.
Insurance Carrier
Policy Number
Doctor's Name
City
Phone Number
(
)
MEDICAL HISTORY
Reasonable accommodations will be made for student medical disabilities. Your doctor's statement may be required.
Does your child have any physical handicaps, mental/emotional, or behavioral condititions
about which the COSMOS staff should be made aware? Please state briefly. This information
will support your child's successful participation in COSMOS. Failure to disclose information
will limit our awareness and thereby impede our ability to provide appropriate support or
specialized care, if required.
Yes
No
Is your child currently taking any medications or under a physician's care?
Yes
No
Has your child ever had a reaction to medications under a physician's care?
Yes
No
Does your child have any allergies that we should be aware of? (drugs, foods, insect bites, etc)
Yes
No
If yes, please specify:
If yes, please specify:
If yes, please explain:
If yes, please describe:
EMERGENCY CONTACT
In the event of emergency, if a parent/guardian cannot be contacted, please list someone who you would authorize to
act on your behalf.
Name
Relationship
Phone 1
(
)
Phone 2
(
)
PERMISSION TO PROVIDE COMMONLY USED MEDICATIONS
I authorize the COSMOS Administration to provide the following over-the-counter medications: Tylenol,
asdAdvil, Pepto Bismol, at the request of my son/daughter.
I do not give permission for the COSMOS Administration to dispense any medications to my son/daughter.
PERMISSION AND ACKNOWLEDGEMENT
I understand that the COSMOS staff will try to contact the parent in case of illness or injury. In case of illness or
injury, and when in the judgment of the staff, emergency medical attention is warranted, I authorize the staff to seek
medical attention for my child. If deemed necessary, I give permission for my child to be taken by the Paramedics or
ambulance to a hospital, and for the doctor there to take appropriate action necessary to meet the emergency.
I understand and agree with all the information that is provided on this waiver.
Print name of Parent/Guardian
Signature of Parent/Guardian
Date
Print name of Participant
Signature of Participant
Date
**Please provide copy of the front and back of your child’s insurance card**