We are glad that you are visiting our campus, and we hope that your experience at Valparaiso University is helpful and enjoyable. If you have not yet done so, please call the Admission Office at 219-464-5011 to schedule your overnight visit; this form is a medical consent form and does not set up your overnight experience.

Participant Information

Full name:

Date of Birth:

Age:

Sex:

Street Address:

City:

State:

Zip:

Home phone:

Cell phone:

Email:

Parent/Guardian Information

Name:

Work Address:

City:

State/Province:

Zip:

Work phone:

Cell phone:

Email:

Parent/Guardian Information

Name:

Work Address:

City:

State/Province:

Zip:

Work phone:

Cell phone:

Email:

Emergency Contact

If neither parent/guardian are available in an emergency, notify:

Name:

Work Address:

City:

State/Province:

Zip:

Work phone:

Cell phone:

Email:

Allergy/Dietary Information

Allergies: Insect stings, medications, hay fever, asthma, other. Please list severity of condition and treatment. For example, ice, prescription, over-the-counter medications.

Dietary Restrictions: Please list food allergies, reaction to food, and any treatment used; also list any religious or vegetarian restriction or requirements

Health Concerns: Please list any serious or chronic medical conditions; or recent illness/surgery. Please give dates.

Insurance Information

Insurance Company:

Insurance Company Phone Number:

Permission, Medical Authorization, and Release Statement

The health history is correct so far as I know and I acknowledge that it is important for the provision of proper medical care (if deemed necessary) during a campus visit. I fully understand the dangers, hazards, and risks inherent in the Valparaiso University Overnight Visit. I further acknowledge that the University will not administer regularly prescribed medication. Should the University be unable to reach parent/guardian or the emergency contact person immediately to inform them of an emergency medical issue, I authorize the University or medical agency to initiate treatment in these circumstances. I understand and agree that Valparaiso University assumes no responsibility for any injury or damage that might arise out of or in connection with such authorized emergency medical treatment. I hereby release The Lutheran University Association, Inc., d/b/a Valparaiso University from all actions, damages, claims or demands which I, my heirs, executors, and administrators, or assigns may have against Valparaiso University, its successors, or assigns for all injuries caused by, related to, or arising out of my voluntary participation in the Valparaiso University Overnight Visit Program. I also understand that Indiana State Law and Valparaiso University policy prohibits those who are under 21 years of age from buying or consuming alcoholic beverages, and that the illegal use, possession, distribution, or sale of any illegal drugs is prohibited by state and federal law, in addition to Valparaiso University policy. Any violation of these policies may result in disciplinary action, and/or possible arrest.

Electronic Signature:

Name: Date:

 By clicking here I verify my electronic signature

If the Prospective Student Visitor is a minor and under the age of 18:

I, the undersigned parent or guardian, do hereby grant my permission for my daughter/son to visit Valparaiso University for participation in the Valparaiso Overnight Visit program. In the event of an injury or illness during this visit, medical care may be sought for my child; as the urgency or emergency warrants. I understand that the university will attempt to contact me regarding my child’s condition, however medical care will not be delayed if I cannot be reached. I hereby release Valparaiso University and their agents, employees, and representatives from any and all claims and liability arising in any way out of its exercise of this authority. I understand and agree that all bills for medical care and treatment will be forwarded to my insurance company or me, and that it will be my responsibility to see that such bills are paid. I hereby release The Lutheran University Association, Inc., d/b/a Valparaiso University from all actions, damages, claims or demands which I, my heirs, executors, and administrators, or assigns may have against Valparaiso University, its successors, or assigns for all injuries caused by, related to, or arising out of my child’s voluntary participation in the Valparaiso University Overnight Visit Program.

Electronic Signature:

Name: Date:

 By clicking here I verify my electronic signature