Consent for Emergency Medical Treatment & Transportation CONSENT FOR EMERGENCY MEDICAL TREATMENT AND TRANSPORTATION Student's Name Last Name * First Name * Middle Name Date of Birth * Social Security Number Type of Health Insurance Policy Number Consent Guardian/Parent 1 Name 1 By checking the box and proceeding, I am electronically signing this Agreement. I agree to the terms of this Agreement, effective as of today’s date. Agree Guardian/Parent 2 Name 2 By checking the box and proceeding, I am electronically signing this Agreement. I agree to the terms of this Agreement, effective as of today’s date. Agree reCAPTCHA If you are human, leave this field blank. Submit
