New friends, memories and knowledge to last a lifetime are just part of what your child will experience at the QuarkNet workshop on the Bloomington campus of Indiana University this summer.

Whether or not this is your son's or daughter's first time away from home, we know you still worry. What happens if he or she gets sick or injured and you can't be reached right away?

At Indiana University, we share your concern. That's why we ask that you fill out this form and return it as soon as possible to the QurarkNet lead teachers. If he or she gets sick or injured, this form provides vital medical information. It does not mean that every effort won't be made to contact you first, but it does mean that your child can still be treated quickly even if you can't be reached.

Remember, this form will probably never be used. Safety is our number one priority at IU, especially where children are concerned. Peace of mind is worth the few minutes it takes to complete this form. Please do it today, and then relax while your child looks forward to a special week at IU.

Consent for Medical Treatment of a Minor

Printed Name Printed Name

I, , being the parent or legal guardian of grant the following authorization for medical and/or surgical treatment of this minor by a health care professional should the need arise while he/she is attending the QuarkNet workshop for the time period June 10, 2001 though June 16, 2001.

Please complete one of the following (1, 2 or 3):

1. I grant permission to the Directors, Assistants, or other persons responsible for his/her care to act on my behalf for said minor in granting permission for evaluation and treatment of medical problems. I understand that should a major medical problem arise, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I hereby give my consent to such medical treatment as deemed necessary, including surgery, x-ray examinations and anesthesia to be rendered to said minor by a licensed physician or nurse.

Date Parent/Guardian Signature

2. I do not wish medical care of any kind except in case of an emergency.

Date Parent/Guardian Signature

3. I authorize limited medical care as follows:

Date Parent/Guardian Signature

Medical Information (please print)

Participant's name Social Security Number - -

Age Birth date Date of last Tetanus Toxoid

Past health/injuries Present health

Allergic reactions

Present medication

Other information that would be useful in the event medical treatment is necessary.

Contact Information (please print)

In an emergency, parents or legal guardians can be reached as follows:

Name Relationship to minor

Address Daytime phone

City/State/Zip Evening phone

Name Relationship to minor

Address Daytime phone

City/State/Zip Evening phone

Name Relationship to minor

Address Daytime phone

City/State/Zip Evening phone

Insurance Information (please print)

Parents or legal guardians are responsible for the cost of a minor's medical treatment. When available, insurance information will be processed by the health facility performing the treatment, otherwise you will be contacted for payment by cash, check or credit card.

In an emergency, parents or legal guardians can be reached as follows:

Insurance company Address

City/State/Zip Relationship to minor

Policy Holder's Name Policy number