Rock valley college upward bound

Upward Bound Program
3301 N. Mulford Rd. Rockford, IL 61114-5699 (815) 921-4235 PARENT CONSENT FOR PARTICIPATION

The undersigned does hereby give permission for, our (my) child to attend and participate in the activities sponsored by the
Rock Valley College Upward Bound Program, to ride any vehicle designated by the UB Program Staff in whose care the
minor has been entrusted while attending and/or participating in program activities. I agree not to hold the Upward Bound
Program, its staff, or Rock Valley College liable for any loss or injury that may occur during my child’s participation in
Upward Bound activities.
I understand that while my son/daughter is an Upward Bound participant, he/she will participate in a variety of academic,
cultural enrichment and recreational activities. My son/daughter will abide by the rules and regulations stipulated by the
RVC Upward Bound Program, Administration and Staff, and is subject to dismissal from the Upward Bound program if these
rules are violated.

We (I) authorize the adult, in whose care the minor has been entrusted to consent to any X-ray, examination, anesthetic,
medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special
supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on the
medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said
The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental
services rendered to the aforementioned child pursuant to this authorization.
Hospital Insurance?
List all allergies or special medical problems that your child may have Rock Valley College Upward Bound
The purpose of this form is to enable minor students and adult students to receive emergency medical or dental treatment should they become ill or injured on this trip and under the authority of Rock Valley College Upward Bound and their parents or legal guardians cannot be reached. Please read the section that follows and print and sign your name on the appropriate lines below. In the event reasonable attempts to contact Parent/Guardian Name (Print)/Emergency Contact Person have been unsuccessful, I give my consent for
to receive any treatment deemed necessary by a licensed medical doctor or dentist and the transfer of the student
to a hospital in the area of this trip. This authorization does not cover major surgery unless the medical opinions
of at least two other licensed medical doctors or dentists, agreeing on the necessity for such surgery, are obtained
prior to the performance of such surgery.
Please provide information concerning the student’s medical history and describe any physical impairments or
conditions (including any allergies) requiring the use of medications and to which physicians should be alerted.
Also, please list any medications currently used by the student that will be brought on the trip.
My student has these medical conditions:

My student has no medical conditions.
My student takes the following medications:

Please review the list of over-the-counter medications below and check the ones that you permit your child to be given during Upward Bound program activities. If a preferred medication is not listed, please write it on one of the blank lines. If you do not want the Upward Bound program to administer any over-the-counter medicines, please indicate.
I do not authorize Upward Bound to give my student any over-the-counter medicines.

I authorize the Upward Bound program to administer the following over-the-counter medicines
as indicated below.

Loratadine (Antihistamine) (Non Drowsy) ______Benadryl – (Diphenhydramine) (Drowsiness) Other (Explain)


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CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) Preferred Drug List Choices for Managing Children and Adults with Asthma (2007): Levabuterol inhaler (XOPENEX®) (Tier 3) (SPIRIVA®) maintenance use only (Tier 2) Metaproterenol inhaler (ALUPENT®) (Tier 3) Pirbuterol (MAXAIR AUTOHALER®) (Tier 3) Prednisolone sodium (PRELONE®) (Tier 3) Cro

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