Sample Emergency Contact Information and Consent-to-Treat Form

U.S.-[FOREIGN SITE] Research Experience for Undergraduates (REU)
Department of ABC
XYZ University

Participant’s Name: ______________________________________________________
Date of Birth: ____________ (mm/dd/yy)

Participant’s Home Address:	________________________________________________
	________________________________________________
Participant’s Home Phone:	______________________________________
Participant’s Emergency Contact Information:
In emergency, please contact:	________________________________________________
Relationship:	______________________________
Home Phone/Fax:	______________________________
Work Phone/Fax:	______________________________
Alternate Contact:	________________________________________________
Relationship:	______________________________
Home Phone/Fax:	______________________________
Work Phone/Fax:	______________________________
Personal Physician:	________________________________________________
Phone/Fax:	______________________________
Medical Insurance (include both domestic and international policies, as appropriate):
Carrier:	____________________________________
ID #:	____________________________________
Carrier:	____________________________________
ID #:	____________________________________
Personal Dentist:	________________________________________________
Phone/Fax:	______________________________

Consent to Treat:

I, the undersigned participant in the U.S.-[FOREIGN SITE] REU Program, if I am unconscious or incapacitated, do consent to emergency medical treatment as recommended by a physician during my participation in the Program. Additionally, I give my permission for Program administrative staff to authorize appropriate emergency medical treatment as recommended by a physician during my participation in the Program. This authorization shall continue in force until the conclusion of the Program on [DATE].

____________________________________________	_____________________
Participant’s Signature	Date

If the participant is under twenty-one (21) years of age, a parent or legal guardian through signature below must also give their permission for emergency medical treatment under the above conditions.

____________________________________________	_____________________
Parent’s/Guardian’s Signature	Date
____________________________________________
Parent’s/Guardian’s Name (printed)

OR

(check box) I refuse to give my consent to emergency medical treatment as recommended by a physician during my participation in the Program. Furthermore, I refuse to give my permission for Program administrative staff to authorize appropriate emergency medical treatment.

____________________________________________	_____________________
Participant’s Signature	Date

If the participant is under twenty-one (21) years of age, a parent or legal guardian through signature below must also refuse their permission to treat the participant in the event of a health or medical emergency.

____________________________________________	_____________________
Parent’s/Guardian’s Signature	Date
____________________________________________
Parent’s/Guardian’s Name (printed)

Rev. 03/2002

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Last updated April, 2002 by Joan Marler