UNIVERSITY OF KENTUCKY …

              UNIVERSITY OF KENTUCKY                                                                CAMPS/CONFERENCES/FIELD TRIPS
                                                                                                       INSURANCE / MEDICAL FORM


              Participant's Name____________________________________ Birth Date_______________ Social Security #___________________
DATE:




               University of Kentucky activities are covered by Allen Flood Insurance. This insurance plan is secondary to the participant's own
               primary plan. For detailed information regarding the policy coverage benefits and limits please visit the U.K. Risk Management
               website at http://www.uky.edu/EVPFA/Controller/riskhome/excess.html or call 859/257-3708.

                You MUST submit a copy of the front and back of all health insurance cards covering participant.
                                                    Check box and sign below if participant has NO health insurance coverage.

                                      __________________________           _____________________________________________________________
                                      Date                                 Signature (Parent/Guardian if claimant is a minor, under 18)


                                                  Disabilities accommodated with advanced (4-6 weeks) notification.
CAMP:




                                                       Consent to Medical Treatment/Insurance Statement
                  It is understood that authority is given to the U.K. activity director or their designee, to have my son/daughter treated for injuries or
               illnesses they incur during a U.K. camp, conference, or field trip activity.
                   In the event I cannot be contacted, I hereby give my permission for the U.K. activity director or their designee to seek advanced medical
               treatment for my son/daughter as deemed necessary by competent medical personnel.
                   I understand that the U.K. insurance coverage is on an "excess" basis only and I will be responsible for any expenses outside of the limits
               of U.K.'s insurance.

                                                               Authorization To Release Information
               I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release any information regarding my
               medical treatment or benefits payable, including disability to any Allen Flood company, the Plan administrator or authorized personnel for
               the purpose of validating and determining benefits payable. This data may be extracted for use in audit or statistical purposes. I
               understand that I or my authorized representative will receive a copy of this authorization upon request. This authorization or a Photostat
               copy of the original shall be valid for the duration of the claim.
FIRST NAME:




               PAYMENT AUTHORIZATION: I authorize all current and future medical benefits for services rendered and billed as a result of this claim
               to be made payable to the physicians and providers indicated on the invoices.

               ___________________________                     _______________________________________________________________________
               Date                                            Signature (Parent or Guardian if claimant is a minor, under 18)


                                                                   Emergency Contact Information

               Name:__________________________________________________                          Relationship: ______________________________
                             (please print)
               Phone number during activity dates:(______)__________________                    Additional number:(____)____________________

              MEDICAL SCREEN FORM (to be completed by a Physician) OR provide a copy of a physical exam form signed by a physician
              indicating clearance to participate. This form must be dated within 12 months of the date of the camp.
                Head            YES     NO
                ENT             YES     NO                          Asthma                            YES                NO      (circle one)
                Neck,                                               Currently taking ANY
                Back            YES     NO                          prescription medication           YES                 NO     (circle one)
                Heart           YES     NO                            please list:
                Abdomen         YES     NO                          Date of Last Tetanus Shot or Booster
LAST NAME:




                Genitalia       YES     NO                          Known Allergies
                Extremities     YES     NO
                Comments

               Sports Participation Approved: YES NO                  Physician's Signature: _____________________________________
               Limitations: YES NO                                    Physician's Phone Number: ( )_____________________________
                                                                      Date:

                                  THE ABOVE INFORMATION IS REQUIRED PRIOR TO PARTICIPATION IN ACTIVITY