Dr. Mattie L. Rhodes College Preparatory Educational Program and HBCU College Tour
Please complete and submit both forms below. Also download the form packet, print, sign the additional forms and bring to the Mandatory Orientation.  You do not need to complete the Emergency Contact & Medical Information forms if you submit online.
ALL FORMS MUST BE SUBMITTED OR SIGNED BY THE PARENT/GUARDIAN, NOT THE STUDENT!
Download Form Packet

EMERGENCY CONTACT INFORMATION FORM

BCT EMERGENCY CONTACT INFORMATION FORM

PARENT/GUARDIAN #1

PARENT/GUARDIAN #2

If for any reason I/we cannot be reached, please contact the following person(s) whom I/we hereby authorize to seek emergency medical or surgical care for my/our child.

In the event that the program is unable to reach any of the individuals named above promptly by phone, I/we authorize the program to seek and secure any emergency medical or surgical care for my/our child.  I/We will be responsible for any and all expenses incurred and authorize the medical facility at which treatment is rendered to release all necessary information to my/our insurance company.

MEDICAL INFORMATON AND TREATMENT AUTHORIZATION FORM

BCT MEDICAL INFORMATON AND TREATMENT AUTHORIZATION FORM

Male
Female

PARENT/GUARDIAN INFO

Y
N
Y
N

HEALTH INFORMATION

Please check below any current health condition that may require attention during the Program day. Also download and complete the Medication Authorization Form if your child has health conditions that require medication during the actual Phase II Tour.

Asthma
Inhaler Required
Vision Problems
Glasses
Contacts
Hearing Problems
Hearing Aid(s)
ADD/ADHD
Other

Allergies/Sensitivities (be specific)

HEALTH HISTORY

Y
N

HEALTH & DEVELOPMENTAL HISTORY

Measles
Mumps
Asthma
Chickenpox
Rheumatic Fever
Hay Fever
Diabetes
Epilepsy
Whooping Cough
Poliomyelitis
Ten-Day Measles (Rubella)
Three-Day Measles (Rubella)

Does child have any significant health history, conditions, communicable illness, or restrictions that may affect child's participation in the Dr. Mattie L. Rhodes College Preparatory Educational Program and HBCU Tour youth initiatives program?  

Yes
No

Does child have any significant food/medication/environmental allergies that may require emergency medical care at the Dr. Mattie L. Rhodes College Preparatory Educational Program and HBCU Tour youth initiatives program?

Yes
No
Yes
No

For any medications or treatment required during the course of the Dr. Mattie L. Rhodes College Preparatory Educational Program and HBCU College Tour a Medical Authorization Form must be downloaded and completed.

Yes
No

NON-PRESCRIPTION MEDICATION PERMIT

Please check those medications you give permission for your child to receive (generic equivalent may be used).  I/We understand that medications will be administered with discretion by authorized program employee and in accordance with established protocols developed by the Program.

For headaches/fever/muscle aches/pain/cramps: Acetaminophen (e.g. Tylenol, including junior Strength), Ibuprofen/Advil, including Children's liquid, Motrin), Naproxen (Aleve), Midol, & Excedrin
For bites/allergic rashes: Anti-itching lotion (e.g. Calamine or Hydrocortisone cream l %), Benadryl liquid or capsules.
For nasal congestion/sinus pressure: Decongestant
For sore throat: Throat lozenges (e.g., Cepacol lozenges)
For coughs: Cough drops/lozenges or cough suppressant.
For upset stomach: Antacid liquid or chewable tablets (e.g., Mylanta)
For sun protection: Sunscreen lotion SPF 30.
I DO NOT WANT ANY MEDICATIONS GIVEN TO MY CHILD.

PHYSICIAN & INSURANCE INFORMATION