THE UNIVERSITY OF NORTH CAROLINA AT ASHEVILLE FACULTY SENATE Senate Document Number 2894S Date of Senate Approval 5/5/94 Signature of Senate Chair ___________________________ Date _________________ Action of Vice Chancellor: Approval __________________________________ Date ______________________ Denied __________________________________ Date _____________________ Reasons for denial and suggested modifications: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Statement of Faculty Senate Action: FWDC #2: Medical Authorization From MEDICAL AUTHORIZATION FORM Participant Information NAME _____________________________________________________________ ADDRESS __________________________________________________________ DATE OF BIRTH ____________________________________________________ MEDICAL AUTHORIZATION I authorize the faculty leader to give necessary hospital or medical facility permission for the above named person on my behalf if an emergency demands it and time prevents my direct participation. The above-named individual is covered by the following health and accident insurance which provides coverage while living in the United States. Company Name ______________________________________________________ Policy Number _____________________________________________________ Indicate below any known allergies and/or medications regularly taken. Indicate below any medications that should NOT be taken. Indicate below any other special medical needs or problems. List the address and telephone number of two persons who can be contacted in case of emergency. ___________________________________________________________________ ___________________________________________________________________ ________________________________ Participant's signature Witness __________________________ ________________________________ Parent/guardian's signature if under 18 ________________________________ Return to: Date Department of ____________________ UNCA One University Heights Asheville, N. C. 28804 We honor the principles in the Americans With Disabilities Act and welcome participation of all individuals with disabilities. The following information may be helpful in using SD2894S and SD2994S (Travel/Medical Authorization Form): For students who need to fill out the Travel/Medical Authorization Form, the following procedure is suggested by Dr. Rick Pyeritz, Student Health Service Director. 1. A student who needs to fill out a Travel/Medical Authorization Form should come by the Student Health Service: a. pick up form b. fill out our Medical History form c. we will start a medical chart on the student 2. The student should fill out the authorization form and return it to the professor in charge of the outing. 3. After all the forms have been received by the sponsoring professor, the professor should bring the forms to the Student Health Service. 4. We will place the form in the student's medical file. Please contact Dr. Pyeritz if you or your committee have any additional thoughts or questions.