JOURNEY EAST, A SINO-AMERICAN CULTURAL EXCHANGE

PARENTAL PERMISSION AND AUTHORIZATION

MEDICAL FORM

Student name:_____________________________________________________

Last First Middle

Date of Birth: ____________________________Social Security #: ___________

Month Day Year

Emergency Contacts

1. Name___________________________ 2. Name ______________________

Relationship to Student: _______________ Relationship to Student: __________

Home phone: ( ) ____________________ Home phone: ( ) _____________

Work phone: ( ) ____________________ Work phone: ( ) _____________

Insurance Information

Is your son or daughter covered by medical insurance: Yes ______ No ______

Primary Insurance Company:

Name of Company: ______________________ Policy Number: __________

Address: _______________________________________________________

Street City State Zip

Secondary Insurance Company:

Name of Company: ______________________ Policy Number: __________

Address: _______________________________________________________

Street City State Zip

Does your insurance allow you ONLY to receive treatment at a designated hospital or medical facility? Yes: _____ No: _____

If yes, please indicate at which facility your son/daughter must receive treatment in order to be covered by your medical insurance.

PLEASE PROVIDE A PHOTOCOPY OF EACH INSURANCE CARD