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Medical and Surgical Authorization Form

I hereby authorize and give my consent to the healthcare providers of Whitworth University or their designated licensed provider to perform upon or administer to:

Name of Student (required)

Student's Whitworth ID Number (required)

Verify Student's Whitworth ID Number

any reasonably necessary medical or surgical treatment. I also give permission to administer whatever anesthetic may be necessary or advisable during medical or surgical procedures. This authorization is intended to cover emergency treatment, immunizations, injections, and minor operations and procedures.

In the event of indicated major surgery or major operation, university authorities or healthcare providers are not hereby excused from attempting to contact me by phone, or mail, before relying upon this authorization. This authorization does not entitle the healthcare providers to render any medical or surgical treatment without the student’s personal consent, unless the student is unable to give consent.

This permission is good only while the student is attending Whitworth University and only until the student’s 18th birthday.

Parent/Guardian Name (this will act as your signature) (required)

Parent/Guardian Address (required)

Parent/Guardian City (required)

Parent/Guardian State (required)

Parent/Guardian ZIP/Postal Code (required)

Parent/Guardian Phone (required)

Parent/Guardian Relation to Student (required)