Upward Bound Program

Medical Consent Form

Name of Student: First, MI, Last Name. *

Address: Street, City, State and Zip Code. *

Date of Birth: *

In case of emergency, person to contact if parent/guardian cannot be reached:

First, MI, Last Name: *

Phone number: *

Address: Street, City, State and Zip Code. *

What relationship is the above person to this student? *

Is the student covered by medical insurance? *

If yes, what kind? *

When was the last time your son/daughter has a complete examination?

Date: *

Doctor: *

Address: Street, City, State and Zip Code. *

Phone number: *

I understand that going on field trips and other campus expeditions poses some risk related to travel and my child being in possibly unfamiliar environments. I accept these risks and in consideration of my child being permitted to participate in the Upward Bound Program, I agree that any claim I or my child may have now against UNM, its officers, employees or agents, arising out of my child's participation in Upward Bound, shall be governed by the law of the State of New Mexico, including the New Mexico Tort Claims Act which limits lawsuits against UNM and its employees.

Parent Signature: *

Signature Type: SMS Start Over

After validation, the cell phone number will become part of the electronic signature.

Cell Phone Number:

Enter characters above to send message.

Date: *