ࡱ> /1.c bjbjZZ 38b\8b\2ff8*>~bZZZZZ555$#55555#ZZ85^ZZ5ZӘN*N0~nnn85555555##555~5555n555555555f> : authorization for emergency medical treatment- minor I. MEDICAL INFORMATION (please type or print legibly) a. Name of Minor (last, first, middle) b. Name of Parent/Guardian (last, first, middle) Address (street or P.O. box, city, state, zip code) Telephone Number: Day ( ) Night ( ) c. Minors Physician Address (street or P.O. box, city, state, zip code) Telephone Number: Office ( ) Emergency ( ) d. Minors Dentist Address (street or P.O. box, city, state, zip code) Telephone Number: Office ( ) Emergency ( ) e. Health Insurance Company Name Policy Number Telephone ( ) f. Minors Allergies g. Minors Current Medications h. Minors Special Health Needs II. EMERGENCY MEDICAL AUTHORIZATION I, the undersigned parent or legal guardian of , (name of minor) do hereby authorize The JAVŮŹ of Texas at El Paso and its agents or representatives to consent, on my behalf, to any medical/hospital care or treatment (including locations outside the U.S.) to be rendered to him or her upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization. The effective dates of this authorization are to 20 . Date 20 . (Signature of Parent or Guardian)     THE UNIVERSITY OF TEXAS AT EL PASO 56LM  0 O d n  ' 5 A X a s | ! ' = E S q  B Q [ j   [ \ k l 37:ADNSdlory|jhkUh#: h*=H* h*=>* h*=5CJ h*=5h*=T56lm 1 B C b c } ( p q dhdL$a$q   S k QRSz$a$h*= h#:5 h*=5jhkUhk 10:pYk/ =!"8#$% s666666666vvvvvvvvv666666>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@OJQJ_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٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  111114 q  8@0(  B S  ?(nv JP DOHTr}\`3333333333333333333kk[\kl5577::SSof*=TprYku#:k@@UnknownG.Cx Times New Roman5Symbol3. *Cx Arial3.Cx Times5. .[`)TahomaA$BCambria Math"1hwcgwcg'  !20KqHP  $P#:2!xx 5AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT- MINORSHonors ColloquiumRamos, Vanessa I.Oh+'0  8D d p | 8AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT- MINORSHonors ColloquiumNormalRamos, Vanessa I.2Microsoft Office Word@F#@zc@~N@~N՜.+,0< hp  $The JAVŮŹ of Texas at Austin  6AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT- MINORS Title  !"#$%'()*+,-0Root Entry F˜N21TablenWordDocument3SummaryInformation(DocumentSummaryInformation8&CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q