Students under the age of 18 years)
Please print form, fill out completely and fax to (518) 783-2992 or mail to:
- Siena College Sports Medicine
Alumni Recreation Center
515 Loudon Road
Loudonville, New York 12211-1462
I am the parent or legal guardian of the above referenced minor, who is a student at Siena College. I understand that situations
may arise in which my child or legal ward may need to quickly precure emergency medical treatmentand that it may not be
possible for Siena College to notify me before the emergency care is rendered. I further understand that Siena College will make
it's best effort to notify me at once of a serious accident or illness involving my child or legal ward that comes to attention.
I also understand that there are certin risks inherent in any emergency medical treatment, including the risk that the treatment
may not accomplish the desired objective.
I hereby authorize the Student Health Center for Siena College, and any physicians, health care institutions or other health care
providers that the Health Service deems it appropriate to consult with, to provide my child or legal ward emergency medical care,
psychiatric care, surgery, anesthesia, radiology, medicines, or hospitalization.
Signed Parent/Legal Guardian: _____________________________________________________________________________
Print Athlete's Name: _____________________________________________________________________________________
Date: ____________________________________
