Please be aware that students enrolled in the English language program who are under the age of eighteen
must have a parental medical release form on file in order to participate in the program.
Please read the following PERMISSION FOR EMERGENCY TREATMENT form.
Sign and return the permission form to:
Language and Culture Center
University of Houston
116 Roy Cullen Building
Houston, TX, 77204
Email: lcc@uh.edu
Tel: (713) 743-3030
Fax:(713) 743-3029
PERMISSION FOR EMERGENCY TREATMENT
On rare occasions an emergency requiring hospitalization and/or surgery develops. Since minors may
not, as a rule, be administered an anesthetic or be operated upon without written consent of the parent or
legal guardian, we request that a parent or guardian sign this statement. This is to prevent a dangerous
delay in case an emergency does occur and we are unable to contact parents or guardians.
In the event of a medical emergency involving my son/daughter/ward,____________________________,
Student’s Name
born_______________ I hereby authorize the hospital or acting physician to administer whatever medical
Student’s Birthdate
treatment is deemed necessary, including the administration of an anesthetic and surgery.
________________________
Date
__________________________________________
Signature of Parent or Legal Guardian
__________________________________________
Printed Name of Parent or Legal Guardian