Eureka College New Student Packet 2013-14 | Page 14

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Mandatory Medical Information

If the student entering Eureka College is under eighteen years of age, the following permission to seek
medical assistance when necessary is needed from the appropriate guardian. This permission remains on
file in the Student Programs and Services Office.

In the event of any needed medical treatment, I, _____________________________________________,
Name of Parent/Guardian

give my permission to Eureka College and/or its medical contractor to seek the necessary medical treatment
for ________________________________________________________________________________.
Name of Student

_________________________________________
Parent/Guardian Signature

Statement of Insurance
All students attending Eureka College are required to show proof of health insurance prior to
registration (see Medical Insurance Verification Form), or they must accept the insurance coverage
offered by Eureka College. If a student does not demonstrate proof of insurance, he/she will be billed
an irreversible insurance charge. If Election #2 is not checked, the Health and Sickness Insurance
will be automatically billed. (Parental Group Insurance is primary in all cases.)
______ 1.

I elect the College-sponsored Health and Sickness insurance
(Premium to be added to student’s account).

______ 2.

I do not elect additional coverage under the College–sponsored Insurance plan.

______ 3.

I realize that if I am an athlete, I must accept the NCAA Insurance Coverage.
I realize that this is not the same insurance as provided by the Health and Sickness
Insurance outlined in Elections #1 and #2.

Signature _____________________________________________________________________________
Parent/Guardian if student is under 18 _______________________________________________________

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