Student & Health Information for Bates College Off-Campus Short Term Courses

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1 Student & Health Information for Bates College Off-Campus Short Term Courses 1. Name Program/Course Bates ID # Cell phone: Home Address: Date of Birth Nationality If course is going abroad, attach a copy of your passport picture & information page, after checking that you have signed your passport and that it is valid through next December. 2. Emergency Contact information Mother Cell phone Home phone Home address (if different) Father Cell phone Home phone Home address (if different) Preferred contact if living separately Mother, Father, Other (provide contact information here) Health Information Study off campus can take students to remote locations and challenging situations. The settings often aggravate existing health issues. In addition, quality medical care is often difficult and slow to obtain. Psychological and counseling support often does not exist. As a result, faculty leading the courses need information on student health physical and emotional that is not required when studying on campus. Health Insurance provider Insurance company: Policy # Telephone number (not a 800 number if studying abroad):

2 Physician(s) providing current care Name Office tel. Specialty Name Office tel. Specialty Information on your allergies, if any (please circle yes or no as appropriate) Do you have any allergies? Yes No If yes, please answer the questions below. (If no, proceed to the next page.) What are you allergic to? What are your symptoms? What is your treatment? If you manage the allergy with a medication, what is the medication, and will you bring it with you when abroad? Do you travel with an epi pen? Information on special dietary needs, if any Information on recent or chronic medical issues, if any (please circle yes or no as appropriate) (List everything here asthma, diabetes, depression, eating disorders everything) Do you have any restrictions on physical activities? Yes No If yes, please describe Have you experienced a serious medical condition(s) or disabling illnesses in the last year? Yes No If yes, please describe Continue on next page

3 Do you have any chronic or recurrent illnesses or disabilities? Yes No If yes, please describe Are you currently under the treatment of a doctor or other medical professional? Yes No If yes, please describe Are you currently prescribed any medications? Yes No If yes, please describe If not mentioned above, are you currently under treatment, including counseling for any psychological issues, such as depression or anxiety? Yes No If yes, please describe Are there any medical issues, recent or current, which you have not discussed which might be an issue while abroad? Yes No If yes, please describe them and how you are managing them. Continue on next page

4 Authorization to release medical information and to provide emergency care With your signature below, you authorize the faculty member teaching the course, the Bates Health Center staff, and off-campus study office staff to discuss information in this document, information in the parental notification page, and health information created or maintained by the Bates Health Center staff. You understand that the health information may contain information about identity, history, and diagnosis of a medical condition, and may reference treatment for physical care, psychiatric care, substance abuse counseling, illness and/or medication use. State and federal laws require your specific consent to disclose any of the following information: Circle one response for each of the four statements below: diagnosis of drug or alcohol abuse. If I authorize the release of such information, I understand that it cannot be re-disclosed by a recipient without specific consent. diagnosis of mental health. I DO NOT I DO wish to review Health Center information before it is released. I understand any such review must be supervised. diagnosis of HIV infection, ARCS or AIDS. I understand that there have been instances (unrelated to Bates) where individuals disclosing such information have encountered discrimination from others in the areas of employment, housing, education, life insurance, health insurance and social and family relationships. If you need medical treatment while you are participating in the course above, you authorize health care providers to disclose your health information to the faculty member. You also authorize the sharing of your heath information with your medical providers, the professionals treating you, Bates staff, and your parents or other contact person. Your signature also authorizes emergency medical care, including anesthetic and surgery, if you are not able to provide your consent and delaying care might jeopardize your physical wellbeing or life. This authorization is effective until 30 June You are entitled to a copy of this authorization. You may revoke this authorization at any time prior to its expiration date by notifying the faculty member in writing, but the revocation will not have any effect on any actions that were taken before revocation was received. You also understand that you are not required to sign this form to receive any health care benefits (enrollment, treatment, or payment). The information that is used or disclosed pursuant to this authorization may be re-disclosed by the receiving entity. Student Name Signature Date Return this completed form to the faculty member leading your course

5 Parental Notification of Participation on a Bates College Off-Campus Short Term Course This form is available online at: Students participating on Bates Short Term courses that travel off-campus must provide a written statement by their parents or guardians to confirm that these individuals are aware of the student s plans. We also ask that a parent alert the faculty of any medical or psychological concerns regarding their daughter or son s participation. Parents are invited to learn more about the College s Off-Campus Study Program online at < Information on various countries, including travel advisories issued by the U. S. Department of State, is available at < Health information related to travel abroad is available at < I am aware that is participating on a Bates College Short Term course that includes travel to (please fill in the student s destination):. To the best of my knowledge, there are no medical or psychological concerns that will interfere with my daughter or son s participation in the course and additional travel. My daughter or son has a medical or psychological issue(s) which the faculty member should discuss with her or him as it may interfere with the course and additional travel. Date Name: Signature: Telephone at home: Telephone at work: Cell phone: Address: Person to be notified in case of emergency, if different: Name Relationship Address Cell phone: Telephone Please return this form to the Off-Campus Study Office Bates College, 9 Andrews Road, Lewiston, ME Fax:

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