**Due to the potential risk of harm to the unborn fetus, pregnant females will not be allowed to participate in this program. If you are or believe you may be pregnant notify CLAHEC immediately.**
In case of a serious illness, I hereby authorize hospital officials to make whatever arrangements necessary and to contact me immediately. I understand that it remains my responsibility to make any future changes in the information on this medical form as the need arises, by contacting Central Louisiana AHEC.
Otherwise, this authorization will remain in effect as it appears this date. Neither Central Louisiana AHEC, LSU-Alexandria, nor Franciscan Missionaries of Our Lady University assume responsibility for medical charges.
As the parent or guardian of the afore mentioned student, by checking this box, I give my child permission to apply for the CI: Healthcare program. Checking this box also authorizes Central LA AHEC the use of my child's image and statements; uses include, but are not limited to: photography, videotape, organizational web site, or social and/or print media. Additionally, I grant Central LA AHEC permission to use my child's personally identifiable information for the purposes of federal, state and grant tracking and reporting.