USF Pre-College
Health Information and Accommodation Request Form
Program ___________________________________________________ Date(s) ________________________
Student’s Full Name_________________________________________________________________________
Date of Birth ____________________________________ Grade _____________________________________
Home Street Address________________________________________________________________________
City __________________________________________ State _____ ZIP _______Phone__________________
HEALTH/SPECIAL NEEDS INFORMATION
(Attach additional sheets as necessary to fully respond to the following questions.)
Does the student have any allergies that we should know about prior to emergency treatment?
o Yes o No If yes, please describe:
Does the student have any chronic conditions/illness that we should know about prior to emergency treatment?
o Yes o No If yes, please describe:
Does the student require an ADA/504 or medical accommodation for disability to participate in the program?
o Yes o No
If yes, please identify type of disability: o Hearing o Physical/Medical o Learning o Psychological
Does the student need an accommodation in the housing room?
o Yes o No If yes, please explain:
Innovative Education | 4202 E. Fowler Ave., LIB608, Tampa, FL 33620 | Phone 813-974-8031 | Fax 813-974-7272
PC_HealthForm_02/2016
USF Pre-College
Will the student need an accommodation to participate in the classroom?
o Yes o No
If yes, please select type of accommodations:
o Materials in alternative format
o Wheelchair accessible furniture
o ASL or Real time Captioning
o Extended time to complete exams/activities
o Other
MEDICATIONS
Please list any medications you are currently taking:
Prescription
Dosage
Doctor
Special Instructions
MEDICAL AUTHORIZATION
The University of South Florida is also authorized to provide or to arrange for any medical treatment the student may need
during the course of this program. I understand and agree to be responsible for any and all costs associated with such
services. In the event of illness or injury, I wish to be contacted at the following telephone numbers:
Home _______________________ Work _______________________ Mobile___________________________
In addition to authorizing medical care, I hereby certify that any charges related to the medical care given to the student
will be borne by me. The insurance company and policy information that covers the student is as follows:
Insurance Carrier
Policy Holder
Policy Number
I understand the medication prescribed by my Physician will be kept in a locked box by the staff while I am participating
in the program. It is my responsibility to obtain the medication from the staff and take the medication as directed by the
physician. By checking the box and typing my legal name below, I hereby attest that the information provided in this form
is correct to my knowledge.
o Student Name _________________________________________________________ Date______________
o Parent/Guardian Name____________________________________________________ Date______________
Please complete and send to [email protected]
Innovative Education | 4202 E. Fowler Ave., LIB608, Tampa, FL 33620 | Phone 813-974-8031 | Fax 813-974-7272
PC_HealthForm_02/2016