ࡱ> 796 bjbj@@ 3* k* k2zzsssss8yS sss3jss@A u4BI0yvRs@yz 9: authorization for emergency medical treatment- minor I. MEDICAL INFORMATION (please type or print legibly) a. Name of Minor (last, first, middle) b. Name of Parent/Guardian (last, first, middle) Address (street or P.O. box, city, state, zip code) Telephone Number: Day ( ) Night ( ) c. Minors Physician Address (street or P.O. box, city, state, zip code) Telephone Number: Office ( ) Emergency ( ) d. Minors Dentist Address (street or P.O. box, city, state, zip code) Telephone Number: Office ( ) Emergency ( ) e. Health Insurance Company Name Policy Number Telephone ( ) f. Minors Allergies g. Minors Current Medications h. Minors Special Health Needs II. EMERGENCY MEDICAL AUTHORIZATION I, the undersigned parent or legal guardian of , (name of minor) do hereby authorize ͷ and its agents or representatives to consent, on my behalf, to any medical/hospital care or treatment (including locations outside the U.S.) to be rendered to him or her upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. The effective dates of this authorization are to 20 . Date 20 . (Signature of Parent or Guardian)     THE UNIVERSITY OF TEXAS AT EL PASO 456LMlm   0 1 O d n  ' 5 A B C X a b c s | } ! ' ( = E S p q r hDh*=>*mH sH hDh*=mH sH  h*=H* h*=>*h*= h*=5CJ h*=5 hDh*=O56lm 1 B C b c } ( p q dhdL$a$gdDq   S k QRSz$a$    B Q S [ j k   [ \ k l 37:ADNQRSdloryz| h#:5 h*=5hSjhSUh#: h*=H* h*=5CJ h*=>*h*=hDh*=mH sH A10:pYk/ =!"8#$% x666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666OJQJ_HmH nH sH tH <`< NormalCJ_HmH sH tH DA D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List 4@4 Header  !4 4 Footer  !:>@: Title$a$ 5:>*CJH"H #:0 Balloon TextCJOJQJ^JaJN/1N #:0Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vzt7.??Źڨd/L+[梃 _¯UjyA_/֖j-A %4\/%ި+K|h(Kmgk):b| H$Y 9DZ.6)A2&`RV!*_[`dI+^DL-)>qfoΟ~_'ҨrQrW_ƿw!pƦ7/_zqԵbp@m ?ItDl,(CjLQc׎O9!N@Iw{Xe3b|`:2˭A9Tn$ءy@Q&Q3,;sg8v%= CN4I ~> zHzw0u $J}*;(wL|$C޳q-!1,hEX>ZN yݾKt l&;HPm%6sq !&}] ~@Lw?%q d98@7C̜mia_Y㩓b8F vB{cNQqsu;6~@VƾzXU+f:OllD,E|=mVePاcGxe_+gj=HSԳ;{yи½|mHmA`0D_cU\+w/ 9MOJK:WnǯIUsffn`<"K*2:&w4]3۸cB/br;}̸uF̘G}ҙ3>-=k&ڂE%睸 |Te6pp1GZ&L~AdNPjĢP gFFz٫[ euRTVxC'c*ibQTz:"dC%1!4ZŲR?rՔ)Zf\5GμMO20V4'|:xt&Ԯiv +nD?TWq]_7.u)S 4?⦾@3;S,8;^K=7>̌cC ^$77&%Bn"cy@I K?L'CWc%WSc#^w}ܓ߭ei)$ Z`%v]:Blqwae&De*2JǐYG4OPQRlnຠtSi832IQ QrZ.afٽ\HYʚU6iaT&ly*o]M̹Qh2/woQoPSJŪ[lDY&`Riڊ0z۶ܫ/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!wG theme/theme/theme1.xmlPK-! ѐ'Q theme/theme/_rels/themeManager.xml.relsPK]L 0 111114  q  8@0(  B S  ?v}JPVYkoux 26<?5>HTZ]NQ/AKNfmvy333333333333333333333  ofD*=TprYku#:kS@@UnknownG.[x Times New Roman5Symbol3& .[x Arial3.[x Times5& .[`)TahomaC. Aptos Display3. AptosA$BCambria Math"qhwcg'-@-@20ss Kq@P  $P#:2!xxzd 5AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT- MINORSHonors Colloquium Dan Clouse Oh+'0  0< \ h t 8AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT- MINORSHonors ColloquiumNormal Dan Clouse3Microsoft Office Word@G@zc@~N@t ՜.+,0< hp  $The University of Texas at Austin@-s 6AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT- MINORS Title  !"#$%'()*+,-/0123458Root Entry F@A u:Data 1TableWordDocument3SummaryInformation(&DocumentSummaryInformation8.CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q