Palm Beach State College Student Emergency Contact and Medical Treatment Form
CLUB INFORMATION
Club Name
*
Club Advisor Email
*
example@pbsc.edu
Campus
*
Please Select
Belle Glade
Boca Raton
District
Honors College
Lake Worth
Loxahatchee Groves
Palm Beach Gardens
SA Campus Email
PERSONAL INFORMATION
Name
*
First Name
Last Name
Student ID
*
Student Email
*
example@my.pbsc.edu
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
DOB
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
EMERGENCY CONTACT
Contact Name
*
First Name
Last Name
Relationship to the Student
*
Contact Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
EMERGENCY MEDICAL INFORMATION
Please check any of the following that apply to you:
Allergies
Asthma
Diabetes
Fainting Spells
Convulsions
Wear Contact Lenses
Wear Dentures
Bleeding
Have a Pacemaker
Other
Specify any other medical conditions or information:
PERMISSION FOR EMERGENCY TREATMENT
I/We authorize the appointed representative(s) of Palm Beach State College to obtain and authorize medical treatment as is necessary to protect the student’s well-being, including authorization for emergency treatment,anesthesia, and/or surgery as deemed necessary. Further, I/we do hereby release and agree to hold Palm Beach State College, employees, administrators, agents and Board of Trustees harmless from any and all claims and causes of action which might be brought by myself, parents, spouse, dependents, heirs, executors and administrators for loss of property, personal injury or death sustained by the student arising out of any travel or activity conducted by or under the control of Palm Beach State College.
Student Signature
*
Date
*
-
Month
-
Day
Year
Date Picker Icon
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date Picker Icon
Submit
Should be Empty: