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The forms request details on primary care physician, immunization status, limiting medical conditions, current medications, allergies or reactions, and any other relevant conditions. 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The following information will not be used by The University of Tennessee to determine Participant’s ability to participate safely in the Program.\u003Cbr>Participant’s Primary Care Physician’s Name and Phone Number: |  |\n| Date of Participant’s most recent tetanus toxoid immunization:\u003Cbr>____________________________________________________________________________ ________\u003Cbr>pg. 1 |  |\n\nFor the following questions, please circle a response and explain as appropriate:  \n\n| Does participant have any limiting medical conditions that Participant, you, and/or Participant’s doctor believe may limit Program participation? If “yes,” please identify the condition and explain its limiting effect: (use the back of this form or a separate sheet if necessary) |  YES   NO |\n| --- | --- |\n| Is Participant currently taking any medication that Participant, you, and/or Participant’s doctor believe may interfere with his/her ability to participate safely or effectively in the Program?\u003Cbr>If “yes,” please identify the medication and explain its potential effect: (use the back of this form or a separate sheet if necessary) |  YES   NO |\n| Does Participant have a history of allergies or reactions to medications, insect stings, plants, or foods?\u003Cbr>If “yes,” please explain the history: (use the back of this form or a separate sheet if necessary) |  YES   NO |\n| Does Participant have a history of, or currently suffer from, any other medical condition(s) of which the Program staff needs to be aware?\u003Cbr>If “yes,” please identify the medical condition(s) and explain what the Program staff needs to know: (use the back of this form or a separate sheet if necessary) |  YES   NO |\n\nMedical Insurance Information  \nPolicy holder’s name:   Policy holder’s relationship to Participant:   Policy holder’s address:    \n____________________________________________________________________________ ________  \nPlease either attach a photocopy of both sides of your insurance card (preferred) or provide the information requested here:  \nInsurance company name and address: ____________________________________________________  \nInsurance company phone number: _______________________________________________________  \nPolicy numbers: ______________________________________________________________________  \npg. 2  \nEmergency Contact Information  \nName of Participant’s Emergency Contact:   Daytime telephone number:   Evening telephone number:   Relationship to Participant:    \nAuthorization for Medical Treatment  \nIn the event of an accident or serious injury or illness, I hereby authorize The University of Tennessee and its trustees, officers, employees, agents, and volunteers in official and individual capacities (“Releasees”) to obtain medical treatment for Participant. I further agree to accept full responsibility for any and all expe","cbCaiaxR52VtqZvA","https://ap.wps.com/l/cbCaiaxR52VtqZvA","pdf",325933,9,"English","# Medical Information and Medical Treatment Release and Authorization Form (Pages 1-3)\n## Program Information\n## Participant Information\n## Medical Information\n## Medical Insurance Information\n## Emergency Contact Information\n## Authorization for Medical Treatment\n# Authorization for Self-Administration of Prescription Medication (Pages 4-5)\n# Authorization for Dispensation of Over-the-Counter Medication (Pages 6-7)\n# Release, Hold Harmless, and Indemnification Agreement (Pages 8-9)","[{\"question\":\"What medical details must be provided on the forms for GSSE 2020 participants?\",\"answer\":\"Participants must provide primary care physician contact information, the date of the most recent tetanus toxoid immunization, and answers about limiting medical conditions, current medications that could interfere with participation, allergies or reactions, and any other conditions the program staff should know about.\"},{\"question\":\"What insurance and emergency contact information is required?\",\"answer\":\"The forms request the policy holder’s name, relationship to the participant, address, insurance company details, policy numbers, and insurance card information. They also collect the emergency contact’s name, daytime and evening telephone numbers, and relationship to the participant.\"},{\"question\":\"What does the parent or legal guardian authorize regarding medical treatment?\",\"answer\":\"In case of an accident, serious injury, or illness, the parent/legal guardian authorizes the University of Tennessee and its representatives to obtain medical treatment. The authorization includes agreement to accept responsibility for resulting expenses and acknowledges that undisclosed relevant information may cause harm.\"}]","Medical Authorization Forms - GSSE 2020 - Pages 1-9 | PDF",1789618628]