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Health Form


on The Unity Through Knowledge Black College Tour, this to authorize the Rev. Kelcey A. West, Tour Director, or his designee to consent to the rendering of any medical treatment which they consider to be appropriate, if my child is injured or becomes ill during the tour.  This is to further authorize any hospital, physician, emergency medical technician or other health care provider to provide such medical treatment and care as may be required for the health, safety and well-being of my child.  I hereby release any claims which I might otherwise have against any such health care provider for the rendition of medical services to my child in reliance upon this Medical Authorization. I likewise release any claims which I might otherwise have against the Unity Through Knowledge HBCU Tour, 32nd Street Theater and its staff for the authorization of such medical care or treatment for my child as any of the tour chaperones believe to be warranted under the circumstances.

Please check any known health conditions:
Are you currently receiving/taking medication?
Can the student receive over the counter medicine?

Thanks for submitting!

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