STUDENT LEGAL SERVICE
AO CASE INTAKE -- HEALTH CARE/MEDICAL
POWER OF ATTORNEY
http://www.odos.uiuc.edu/sls
NOTE: This form is to be used for designating someone to make Health Care/Medical decisions on your behalf. Please
read the documents in the link to the Illinois Statutes. If you have a Traffic ticket, City Offense/Ordinance Violation ticket, Misdemeanor charge, Housing/Landlord issue, OR want to request for Power of Attorney document
for financial matters,or other issue not listed, please select the correct formsfor those issues on the website.
Students who are assessed and pay the S.O.R.F. fee are eligible to consult Student Legal Services during the semester
that the fee is assessed, until the first day of the next term, including summer.
Once the form is completed, you must print it and bring it into the Student Legal Service Office, during regular office
hours (8:30am-Noon, 1:00-4:30pm) at 324 Illini Union and present it with your I-card. You will then be set up with an
appointment to discuss your issues with an attorney.
Family Name
First Name
Middle
LOCAL ADDRESS:
Dormitory
Street Address: Be sure to include
apartment #
OR
SELECT:
Room #
Champaign
Urbana
Zip Code
Savoy
Other zip code:
61801
Local Landline phone #
Other
Cell Phone #
UIUC Office phone #
Permanent Address:
Street address,
City, State, Zip Code
Permanent Phone Number
May we contact you by email?
Yes
@uiuc.edu
No
Alternate email:
What is your year/class at UIUC?
Freshman
College:
Sophomore
SELECT ONE:
Junior
Senior
Graduate
Law/Vet/Med
Major
REQUIRED: Are you a U.S. Citizen?
Have you used Student Legal Service previously?
Yes
Yes
If not, how did you learn about Student Legal Service (select one)?
Other,not listed:
No
No
SELECT FROM LIST:
VOLUNTARY PROVISION OF SOCIAL SECURITY NUMBER(S):
Student Legal Service is requesting your or other Social Security number (SSN) in order to include it as specific identification on the
Power of Attorney (financial, medical or otherwise) that you are requesting be created on your behalf Student Legal Service will not
disclose an individual's SSN without the consent of the individual or onyone outside Student Legal Service, except as mandated by
law. Student Legal Service is working to minimize the use of Social Security numbers within its business processes. For a full
description of the University of Illinois Social Security number policy, to which we subscribe, please visit: http://www.ssn.uillinois.edu
Your SSN (* See grey box above for policy)
Name of person you wish to give power to make medical decisions:
Address (including city, state, zip code)
Date on which power is to become effective:
OR
Event upon which you wish power to become effective (e.g., court or medical determination of your disability, or other event):
Date or event upon which you want this power to terminate prior to your death:
What limits do you want to impose? ( specific limitations you deem appropriate, such as your own definition of when life-sustaining measure
should be withheld; direction to continue food and fluids or life-sustaining treatment in all events, or instruction to refuse any types of treatment that are
inconsistent with your religious beliefs or unacceptable to you for any other reason, such as blood transfusions, electroconvulsive therapy, amputation,
psychosurgery, voluntary admission to a mental institution, etc.):
Names and addressors of successors if the primary agent dies, becomes incompetent, resigns or refuses to accept the
office of agent, or becomes unavailable:
(1)
(2)
I am a student currently enrolled for the current semester in credit-bearing courses of at least six hours, or
equivalent, at the University of Illinois at Urbana-Champaign
I have been assessed the S.O.R.F. fee of FOURTEEN DOLLARS ($14.00) and have not sought a refund of the SORF fee
at the University for the current semester. If I obtain a refund of anySORF fee while I am consulting with or being
represented by an attorney at Student Legal Service, I understand that I can no longer be represented.
I acknowledge being advised through this form and specifically agree that the Attorneys at Student Legal Service
act independently of the University of Illinois; the Attorneys are neither a part of nor agents of the University of
Illinois.
I understand that this form may be destroyed in five (5) years.
Date:
Signature:
_____________________________________
(Please sign after you print the form)
Print Form